Individual
WANDA M NORTHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4800 TEXAS BLVD STE 100, TEXARKANA, TX 75503-3033
(318) 222-8421
(318) 673-9972
Mailing address
5002 COWHORN CREEK RD, TEXARKANA, TX 75503-9766
(318) 222-8421
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
J0619
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
047789501
—
TX
05
—
119308001
—
AR
Enumeration date
07/28/2005
Last updated
12/31/2020
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