Provider Demographics
NPI:1780684183
Name:NORTHAM, WANDA M (MD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:M
Last Name:NORTHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:318-222-8421
Mailing Address - Fax:
Practice Address - Street 1:4800 TEXAS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3033
Practice Address - Country:US
Practice Address - Phone:318-222-8421
Practice Address - Fax:318-673-9972
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ0619207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119308001Medicaid
TX047789501Medicaid
TX89E253Medicare PIN
D98115Medicare UPIN