Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 277455 | NY |
N | 207Q00000X | Family Doctor | 277455 | NY |
N | 207QA0401X | Family Doctor - Addiction Medicine | 277455 | NY |
NPI | 1437495421 |
---|---|
Provider Name | Robert Wicelinski JR. |
First Address | Elmira, NY 14901-3230 |
Second Address | Elmira, NY 14905-1629 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/12/2012 |
Last Update Date | 01/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04665532 | (05) | NY |