1518073717 NPI number — DONALD E. WENNER M.D. F.A.C.S. P.C.

Table of content: (NPI 1518073717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518073717 NPI number — DONALD E. WENNER M.D. F.A.C.S. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DONALD E. WENNER M.D. F.A.C.S. P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1518073717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 S.E. MAIN STREET STE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-622-4374
Provider Business Mailing Address Fax Number:
575-623-1161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 S.E. MAIN STREET STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-622-4374
Provider Business Practice Location Address Fax Number:
575-623-1161
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZAMORA
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
575-622-4374

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  85-124 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 35246 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com