Healthcare Provider Details

I. General information

NPI: 1912045873
Provider Name (Legal Business Name): SAMEENA SULTANA WAFA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 W CHRISTOFFERSEN PKWY
TURLOCK CA
95382-9547
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-632-3901
  • Fax:
Mailing address:
  • Phone: 855-771-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA97665
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: