Provider Demographics
NPI:1205956265
Name:WANDLER, KEVIN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:WANDLER
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 1:888 S HILLHURST RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-9063
Mailing Address - Country:US
Mailing Address - Phone:754-300-3120
Mailing Address - Fax:954-306-8977
Practice Address - Street 1:11725 POINTE PL
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4636
Practice Address - Country:US
Practice Address - Phone:470-990-9483
Practice Address - Fax:877-800-5436
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA108093002083A0300X, 2084A0401X
CODR.00554652084A0401X
OH1305252084A0401X
MO20220486252084A0401X
WAMD605628142084A0401X
IN01092373A2084A0401X
AZ144212084P0800X
FLME1107162084P0800X
GA926602084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004007100Medicaid
FL004007100Medicaid