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General NPI Number Information
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NPI Number | 1831105543
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Entity Type | Individual
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Provider Name | RICHARD J WYDERSKI MD
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Gender | Male
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 09/27/2022
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Provider Practice Location Address
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Address Line | 1345 36TH ST STE B
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City | VERO BEACH
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State | FL
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Zip | 32960-4811
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Country | US
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Telephone | 772-742-3799
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Fax | 772-742-3797
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Provider Business Mailing Address
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Address Line | 1345 36TH ST STE B
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City | VERO BEACH
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State | FL
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Zip | 32960-4811
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Country | US
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Telephone | 772-742-3799
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Fax | 772-742-3797
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 35-05-5443
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | 2011-00791
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | ME142917
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License Number State | FL
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