Provider Demographics
NPI:1255367678
Name:TEODOROWICZ-MARINO, WANDA (MD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:TEODOROWICZ-MARINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2242 CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-1457
Mailing Address - Country:US
Mailing Address - Phone:914-793-7111
Mailing Address - Fax:914-793-1325
Practice Address - Street 1:2242 CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-1457
Practice Address - Country:US
Practice Address - Phone:914-793-7111
Practice Address - Fax:914-793-1325
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143436207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY143436OtherMEDICAL LICENCE
P1218912OtherOXFORD ID
NY00851501Medicaid
0888912OtherAETNA HMO
143436A-40Other1199
143436A-40OtherHEALTH FIRST 65
NY18002947OtherRAILROAD MEDICARE
4412490OtherAETNA PPO
0091319OtherGHI
NY133295758OtherTAX ID
NY133295758OtherTAX ID
NY00851501Medicaid