Provider Demographics
NPI:1407879596
Name:WYNDHAMSMITH, DAVID RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:WYNDHAMSMITH
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:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-204-6747
Mailing Address - Fax:626-396-0851
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:818-546-5632
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72018207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G720180Medicaid
CA00G720181OtherBLUE SHIELD
CAWG72018DMedicare PIN
CA00G720180Medicaid
CACB254308 (OAP)Medicare PIN