Provider Demographics
NPI:1891006888
Name:MASTERMAN, WENDY J (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:J
Last Name:MASTERMAN
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 1:21758 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6921
Mailing Address - Country:US
Mailing Address - Phone:813-563-6070
Mailing Address - Fax:813-563-6040
Practice Address - Street 1:21758 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-6921
Practice Address - Country:US
Practice Address - Phone:813-563-6070
Practice Address - Fax:813-563-6040
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70973208000000X
FLME117943208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME117943OtherLICENSE