Provider Demographics
NPI:1366568081
Name:WADOWSKI, KATRINA (MD)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:WADOWSKI
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 1:4045 E BELL RD STE 134
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2234
Mailing Address - Country:US
Mailing Address - Phone:602-569-2790
Mailing Address - Fax:602-992-7851
Practice Address - Street 1:4045 E BELL RD STE 134
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2234
Practice Address - Country:US
Practice Address - Phone:602-569-2790
Practice Address - Fax:602-992-7851
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ28184Medicare ID - Type Unspecified
AZG414117Medicare UPIN