Provider Demographics
NPI:1063517050
Name:BOOTE, WANDA M (MD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:M
Last Name:BOOTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8012
Mailing Address - Country:US
Mailing Address - Phone:727-895-3376
Mailing Address - Fax:727-362-3376
Practice Address - Street 1:2060 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8012
Practice Address - Country:US
Practice Address - Phone:727-895-3376
Practice Address - Fax:727-362-3376
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL53607207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070012797OtherRR MEDICARE PROV NUMBER
FL070012797OtherRR MEDICARE PROV NUMBER
FLK8768Medicare PIN
FL07255BMedicare PIN