Provider Demographics
NPI:1285700195
Name:WADAS, THEODORE J (OD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:J
Last Name:WADAS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:38 ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-1550
Mailing Address - Country:US
Mailing Address - Phone:315-736-3217
Mailing Address - Fax:
Practice Address - Street 1:408 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:NY
Practice Address - Zip Code:13417-1239
Practice Address - Country:US
Practice Address - Phone:315-736-3217
Practice Address - Fax:315-736-3217
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV48601152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T26753Medicare UPIN
NY0924410001Medicare NSC
51004BMedicare PIN
0204410001Medicare NSC