Basic Information
| Provider Information | |||||||||
| NPI: | 1417324336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STROH | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOERTJE STROH | ||||||||
| OtherFirstName: | WENDY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 100275 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737839 | ||||||||
| FaxNumber: | 3522738172 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737839 | ||||||||
| FaxNumber: | 3522738172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2015 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZF0201X | OS 5311 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 015759200 | 05 | FL | MEDICAID |