Healthcare Provider Details

I. General information

NPI: 1306833363
Provider Name (Legal Business Name): ABDUL WASE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 N MAIN ST STE 101
DAYTON OH
45415-1180
US

IV. Provider business mailing address

9000 N MAIN ST STE 101
DAYTON OH
45415-1180
US

V. Phone/Fax

Practice location:
  • Phone: 937-832-2425
  • Fax: 937-832-9804
Mailing address:
  • Phone: 937-832-2425
  • Fax: 93-832-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35057815
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number35057815
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: