Basic Information
Provider Information | |||||||||
NPI: | 1700813813 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WENTZEL | ||||||||
FirstName: | CARL | ||||||||
MiddleName: | FRANK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | III | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 634706 | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452630001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8652923000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5818 HARBOUR VIEW BLVD | ||||||||
Address2: |   | ||||||||
City: | SUFFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 234353315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7576735800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2006 | ||||||||
LastUpdateDate: | 11/07/2007 | ||||||||
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 | 207P00000X | 0101047910 | VA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00343469 | 01 | VA | RAILROAD MEDICARE | OTHER | 1700813813 | 05 | VA |   | MEDICAID |