Healthcare Provider Details

I. General information

NPI: 1124225909
Provider Name (Legal Business Name): WAHEEDA SAMADY M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 55
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 55
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 858-254-6988
  • Fax:
Mailing address:
  • Phone: 858-254-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA106192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: