1003826918 NPI number — EUGENE E WENTHE JR. M.D.

Table of content: EUGENE E WENTHE JR. M.D. (NPI 1003826918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003826918 NPI number — EUGENE E WENTHE JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WENTHE
Provider First Name:
EUGENE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1003826918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 S FISKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1223 GATEWAY DR STE 1E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-725-4505
Provider Business Practice Location Address Fax Number:
321-409-6823
Provider Enumeration Date:
08/09/2006

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: 207Q00000X , with the licence number:  036061047 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME117071 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020057300 . This is a "BLACK LUNG" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036061047 . This is a "IL STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 08421024 . This is a "BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 170774 . This is a "PERSONAL CARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036061047 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 054913 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 101343 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 6394P . This is a "CATERPILLAR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CD7143 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 080098256 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 133586700 . This is a "ACS-OWCP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 14D0949277 . This is a "CLIA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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