Provider Demographics
NPI:1427178821
Name:WASSERMAN, THEODORE WOLF (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:WOLF
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CRISTOBAL ST
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34113-8618
Mailing Address - Country:US
Mailing Address - Phone:215-688-6300
Mailing Address - Fax:
Practice Address - Street 1:1400 REED ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-4823
Practice Address - Country:US
Practice Address - Phone:215-755-0500
Practice Address - Fax:215-755-3561
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD006726E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB32477Medicare UPIN
PA015438F6TMedicare ID - Type Unspecified