Provider Demographics
NPI:1013025071
Name:JAMISON, WENDELL BLAKE (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:BLAKE
Last Name:JAMISON
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 1:101 SOUTH B STREET
Mailing Address - Street 2:#C
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-736-7537
Mailing Address - Fax:805-737-6157
Practice Address - Street 1:101 SOUTH B STREET
Practice Address - Street 2:#C
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-736-7537
Practice Address - Fax:805-737-6157
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA17533207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA17533Medicare ID - Type Unspecified
B49870Medicare UPIN