Healthcare Provider Details

I. General information

NPI: 1649270190
Provider Name (Legal Business Name): BOB WODECKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BOB WODECKI

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 OLD MOCKSVILLE ROAD
STATESVILLE NC
28625-1903
US

IV. Provider business mailing address

293 OLD MOCKSVILLE RD
STATESVILLE NC
28625-1930
US

V. Phone/Fax

Practice location:
  • Phone: 704-872-8711
  • Fax: 704-872-5866
Mailing address:
  • Phone: 704-872-8711
  • Fax: 704-872-5866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36856
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number36856
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: