Provider Demographics
NPI:1861471096
Name:WANNA, FADY S (MD)
Entity Type:Individual
Prefix:DR
First Name:FADY
Middle Name:S
Last Name:WANNA
Suffix:
Gender:M
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 6599
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6599
Mailing Address - Country:US
Mailing Address - Phone:205-620-7523
Mailing Address - Fax:
Practice Address - Street 1:4300 W MAIN ST STE 21
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1058
Practice Address - Country:US
Practice Address - Phone:205-620-7523
Practice Address - Fax:205-620-8667
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51616208G00000X
GA43813208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicaid
GA000876895AMedicaid
511I330005OtherMEDICARE
GA33BDBFVMedicare ID - Type Unspecified