Healthcare Provider Details

I. General information

NPI: 1033147699
Provider Name (Legal Business Name): WANDA B IZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 N STATE RD
OWOSSO MI
48867-9075
US

IV. Provider business mailing address

239 N STATE RD
OWOSSO MI
48867-9075
US

V. Phone/Fax

Practice location:
  • Phone: 989-743-3415
  • Fax: 989-743-6180
Mailing address:
  • Phone: 989-743-3415
  • Fax: 989-743-6180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301097720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: