Healthcare Provider Details

I. General information

NPI: 1184724312
Provider Name (Legal Business Name): RICHARD G WANDERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 POPLAR AVE STE 302
MEMPHIS TN
38117-4433
US

IV. Provider business mailing address

4646 POPLAR AVE STE 302
MEMPHIS TN
38117-4433
US

V. Phone/Fax

Practice location:
  • Phone: 901-930-7397
  • Fax: 905-552-3902
Mailing address:
  • Phone: 901-930-7397
  • Fax: 901-552-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number22468
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22468
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number22468
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: