MEDICARE: DR. GEORGE RANDALL WANDLING JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	41882	IA
2	207W00000X	Ophthalmology Physician	036137863	IL
3	207W00000X	Ophthalmology Physician	59282	MN

General Provider Information

NPI Number	:	1083935068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE RANDALL WANDLING JR. MD

Provider Business Mailing Address
First Line	:	3777 COON RAPIDS BLVD NW # 100
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2630
Country	:	US
Telephone Number	:	763-421-7420
Fax Number	:

Provider Business Practice Location Address
First Line	:	3777 COON RAPIDS BLVD NW # 100
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2630
Country	:	US
Telephone Number	:	763-421-7420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	01/31/2017

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