1538279633 NPI number — DR. STEVEN MERRITT WANDERMAN MD FAAOS

Table of content: DR. STEVEN MERRITT WANDERMAN MD FAAOS (NPI 1538279633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538279633 NPI number — DR. STEVEN MERRITT WANDERMAN MD FAAOS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WANDERMAN
Provider First Name:
STEVEN
Provider Middle Name:
MERRITT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD FAAOS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538279633
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1485 N TURQUOISE DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-1398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-774-7757
Provider Business Mailing Address Fax Number:
928-774-7767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1146 W HWY 89A
Provider Second Line Business Practice Location Address:
SUITE C3
Provider Business Practice Location Address City Name:
SEDONA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86336-5768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-774-7757
Provider Business Practice Location Address Fax Number:
928-774-7767
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  036312 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 42698 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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