Provider Demographics
NPI:1598742330
Name:SMITH, WENDALYN (MD)
Entity Type:Individual
Prefix:
First Name:WENDALYN
Middle Name:
Last Name:SMITH
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 1:1090 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3700
Mailing Address - Country:US
Mailing Address - Phone:928-583-1000
Mailing Address - Fax:
Practice Address - Street 1:1090 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3700
Practice Address - Country:US
Practice Address - Phone:928-583-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F56239Medicare UPIN