Healthcare Provider Details

I. General information

NPI: 1295812063
Provider Name (Legal Business Name): ROBERT MARK WLODEK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9895 S MARYLAND PKWY SUITE D
LAS VEGAS NV
89183-7165
US

IV. Provider business mailing address

245 ELKINS CIR
HENDERSON NV
89074-5369
US

V. Phone/Fax

Practice location:
  • Phone: 702-435-3937
  • Fax: 702-436-3937
Mailing address:
  • Phone:
  • Fax: 702-436-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number421
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: