Healthcare Provider Details

I. General information

NPI: 1194285692
Provider Name (Legal Business Name): ANDREW CHARLES WONDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 45TH ST STE 204
WEST PALM BEACH FL
33407-2009
US

IV. Provider business mailing address

2151 45TH ST STE 204
WEST PALM BEACH FL
33407-2009
US

V. Phone/Fax

Practice location:
  • Phone: 954-458-1199
  • Fax: 877-204-4721
Mailing address:
  • Phone: 954-458-1199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME167198
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: