Provider Demographics
NPI:1518932664
Name:UPDIKE, WANDA S (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:S
Last Name:UPDIKE
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 1:1060 E 100 S
Mailing Address - Street 2:L10
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102
Mailing Address - Country:US
Mailing Address - Phone:801-328-1260
Mailing Address - Fax:801-350-4361
Practice Address - Street 1:1060 E 100 S
Practice Address - Street 2:L10
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-328-1260
Practice Address - Fax:801-350-4361
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1738441205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT801401924005Medicaid
E62316Medicare UPIN
UT801401924005Medicaid