Healthcare Provider Details

I. General information

NPI: 1952361941
Provider Name (Legal Business Name): WENDY WHITTICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

5901 SW 74TH ST
MIAMI FL
33143-5150
US

V. Phone/Fax

Practice location:
  • Phone: 305-325-3989
  • Fax:
Mailing address:
  • Phone: 305-666-2427
  • Fax: 305-667-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberME0071467
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: