Basic Information
| Provider Information | |||||||||
| NPI: | 1780691097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANDTKE | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | PO BOX 648 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852757586 | ||||||||
| FaxNumber: | 5852731033 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 648 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852757586 | ||||||||
| FaxNumber: | 5852731033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 247458 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.