Healthcare Provider Details

I. General information

NPI: 1295921740
Provider Name (Legal Business Name): FRANK KLAUS WACKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N CAROLINE ST JHOC 4210
BALTIMORE MD
21205-2000
US

IV. Provider business mailing address

601 N CAROLINE ST JHOC 4210
BALTIMORE MD
21205-2000
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5677
  • Fax: 410-955-8597
Mailing address:
  • Phone: 410-955-5677
  • Fax: 410-955-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD48392
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: