Provider Demographics
NPI:1366639569
Name:WANDA M BOOTE MD PA
Entity Type:Organization
Organization Name:WANDA M BOOTE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOOTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-895-3376
Mailing Address - Street 1:2060 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8012
Mailing Address - Country:US
Mailing Address - Phone:727-895-3376
Mailing Address - Fax:727-362-3376
Practice Address - Street 1:2060 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8012
Practice Address - Country:US
Practice Address - Phone:727-895-3376
Practice Address - Fax:727-362-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL53607174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07255BMedicare PIN
FLB64520Medicare UPIN
FLK8768Medicare PIN