Provider Demographics
NPI:1235375122
Name:SAM F WANIS DO PA
Entity Type:Organization
Organization Name:SAM F WANIS DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMEH
Authorized Official - Middle Name:FAYEZ
Authorized Official - Last Name:WANIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-969-3500
Mailing Address - Street 1:2925 10TH AVE N
Mailing Address - Street 2:SUITE #204
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-3046
Mailing Address - Country:US
Mailing Address - Phone:561-969-3500
Mailing Address - Fax:561-966-8898
Practice Address - Street 1:2925 10TH AVE N
Practice Address - Street 2:SUITE #204
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-3046
Practice Address - Country:US
Practice Address - Phone:561-969-3500
Practice Address - Fax:561-966-8898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7511207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253706100Medicaid
FL253706100Medicaid