Provider Demographics
NPI:1720005614
Name:WANIS, SAMEH FAYEZ (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMEH
Middle Name:FAYEZ
Last Name:WANIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 10TH AVE N
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3000
Mailing Address - Country:US
Mailing Address - Phone:561-969-3500
Mailing Address - Fax:561-966-8898
Practice Address - Street 1:2925 10TH AVE N
Practice Address - Street 2:SUITE 204
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3000
Practice Address - Country:US
Practice Address - Phone:561-969-3500
Practice Address - Fax:561-966-8898
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7511207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46246OtherFL BLUE CROSS/BLUE SHIELD
FL46246OtherFL BLUE CROSS/BLUE SHIELD
FLE0738AMedicare ID - Type UnspecifiedMEDICARE