Healthcare Provider Details

I. General information

NPI: 1144780743
Provider Name (Legal Business Name): PAUL ROBERT WOJACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E 17TH ST DEPT OF
NEW YORK NY
10003-3804
US

IV. Provider business mailing address

300 COMMUNITY DR DEPARTMENT OF RADIOLOGY
MANHASSET NY
11030
US

V. Phone/Fax

Practice location:
  • Phone: 212-598-6655
  • Fax:
Mailing address:
  • Phone: 612-701-8134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number319045-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: