Provider Demographics
NPI:1619994316
Name:MCMICHEAL, WANDA V (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:V
Last Name:MCMICHEAL
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-0091
Mailing Address - Fax:479-635-2010
Practice Address - Street 1:4900 KELLEY HWY
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-5000
Practice Address - Country:US
Practice Address - Phone:479-785-5700
Practice Address - Fax:479-785-5708
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129704001Medicaid
080084040OtherRR MEDICARE
AR129704001Medicaid