Basic Information
| Provider Information | |||||||||
| NPI: | 1063459279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENZEL | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | MARINO CENTER FOR PROGRESSIVE HEALTH | ||||||||
| Address2: | 372 WASHINGTON STREET | ||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812355200 | ||||||||
| FaxNumber: | 7812351103 | ||||||||
| Practice Location | |||||||||
| Address1: | MARINO CENTER FOR PROGRESSIVE HEALTH | ||||||||
| Address2: | 372 WASHINGTON STREET | ||||||||
| City: | WELLESLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812355200 | ||||||||
| FaxNumber: | 7812351103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 81112 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0401340 | 01 | MA | UNITED HEALTH CARE | OTHER | 081112 | 01 | MA | TUFTS | OTHER | BCBS | 01 | MA | J31278 | OTHER | 690827 | 01 | MA | HARVARD PILGRIM | OTHER | 4254630 | 01 | MA | AETNA | OTHER | B10183301 | 01 | MA | CIGNA | OTHER | M21670 | 01 | MA | MEDICARE GROUP PROVIDER | OTHER |