Provider Demographics
NPI:1871539205
Name:WODICKA, SCOTT CHRISTOPHER (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:CHRISTOPHER
Last Name:WODICKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:15 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7381
Mailing Address - Country:US
Mailing Address - Phone:631-581-4400
Mailing Address - Fax:631-277-3750
Practice Address - Street 1:15 PARK AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7381
Practice Address - Country:US
Practice Address - Phone:631-581-4400
Practice Address - Fax:631-277-3750
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY214088208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY214088OtherLICENSE
NY214088OtherLICENSE