Provider Demographics
NPI:1538268115
Name:WADHERA, OM P (MD)
Entity type:Individual
Prefix:DR
First Name:OM
Middle Name:P
Last Name:WADHERA
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 1:415 NORTH PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1912
Mailing Address - Country:US
Mailing Address - Phone:315-866-4627
Mailing Address - Fax:315-866-2160
Practice Address - Street 1:415 NORTH PROSPECT ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1912
Practice Address - Country:US
Practice Address - Phone:315-866-4627
Practice Address - Fax:315-866-2160
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01019149Medicaid
NY01019149Medicaid
NYB87013Medicare UPIN