Healthcare Provider Details

I. General information

NPI: 1164688677
Provider Name (Legal Business Name): JACK LAURENCE WAPNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 LIBERTY RD SUITE F
RANDALLSTOWN MD
21133-1026
US

IV. Provider business mailing address

11100 LIBERTY RD SUITE F
RANDALLSTOWN MD
21133-1026
US

V. Phone/Fax

Practice location:
  • Phone: 410-655-2740
  • Fax: 410-655-4740
Mailing address:
  • Phone: 410-655-2740
  • Fax: 410-655-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberD0026048
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: