Provider Demographics
NPI:1518914217
Name:WANZO, CASSANDRA L (MD)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:L
Last Name:WANZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CASSANDRA
Other - Middle Name:L
Other - Last Name:WANZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:602 BOMBAY LN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5828
Mailing Address - Country:US
Mailing Address - Phone:678-566-1440
Mailing Address - Fax:678-566-1442
Practice Address - Street 1:602 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5828
Practice Address - Country:US
Practice Address - Phone:678-566-1440
Practice Address - Fax:678-566-1442
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0351652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52025676OtherBLUE CROSS BLUE SHIELD
GA000483128AMedicaid
GA26BDCCHMedicare PIN
GAB57465Medicare UPIN