Provider Demographics
NPI:1033147699
Name:IZA, WANDA B (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:B
Last Name:IZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 N STATE RD
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-9075
Mailing Address - Country:US
Mailing Address - Phone:989-743-3415
Mailing Address - Fax:989-743-6180
Practice Address - Street 1:239 N STATE RD
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-9075
Practice Address - Country:US
Practice Address - Phone:989-743-3415
Practice Address - Fax:989-743-6180
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301097720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1033147699Medicaid
MIN53550114Medicare PIN