Provider Demographics
NPI:1669457313
Name:SHUMATE, WENDY (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:
Last Name:SHUMATE
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 1:105 DURIAN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6205
Mailing Address - Country:US
Mailing Address - Phone:760-630-4715
Mailing Address - Fax:760-630-4249
Practice Address - Street 1:105 DURIAN ST
Practice Address - Street 2:SUITE B
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6206
Practice Address - Country:US
Practice Address - Phone:760-630-4715
Practice Address - Fax:760-630-4249
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79455207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15915Medicare ID - Type UnspecifiedPROVIDER #
CAF85977Medicare UPIN