Basic Information
| Provider Information | |||||||||
| NPI: | 1538116967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENDEL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1746 COLE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039148800 | ||||||||
| FaxNumber: | 3037163777 | ||||||||
| Practice Location | |||||||||
| Address1: | 1746 COLE BLVD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804013208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039148800 | ||||||||
| FaxNumber: | 3037163777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 12/18/2014 | ||||||||
| 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 | 2085R0202X | 271018-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 51985 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 870284448JAW | 01 | UT | EMIA | OTHER | 27101812005001 | 01 | UT | BX | OTHER | 870284448008 | 05 | UT | MEDICAID | 107047534101 | 01 | UT | IHC | OTHER |