Healthcare Provider Details

I. General information

NPI: 1891006888
Provider Name (Legal Business Name): WENDY J MASTERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21758 STATE ROAD 54
LUTZ FL
33549-6921
US

IV. Provider business mailing address

21758 STATE ROAD 54
LUTZ FL
33549-6921
US

V. Phone/Fax

Practice location:
  • Phone: 813-563-6070
  • Fax: 813-563-6040
Mailing address:
  • Phone: 813-563-6070
  • Fax: 813-563-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70973
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME117943
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: