1063459279 NPI number — DAVID JOHN WENZEL M.D.

Table of content: DAVID JOHN WENZEL M.D. (NPI 1063459279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063459279 NPI number — DAVID JOHN WENZEL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENZEL
Provider First Name:
DAVID
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063459279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MARINO CENTER FOR PROGRESSIVE HEALTH
Provider Second Line Business Mailing Address:
372 WASHINGTON STREET
Provider Business Mailing Address City Name:
WELLESLEY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-235-5200
Provider Business Mailing Address Fax Number:
781-235-1103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MARINO CENTER FOR PROGRESSIVE HEALTH
Provider Second Line Business Practice Location Address:
372 WASHINGTON STREET
Provider Business Practice Location Address City Name:
WELLESLEY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-235-5200
Provider Business Practice Location Address Fax Number:
781-235-1103
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  81112 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0401340 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 081112 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: BCBS . This is a "J31278" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 690827 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 4254630 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: B10183301 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: M21670 . This is a "MEDICARE GROUP PROVIDER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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