Provider Demographics
NPI:1003826918
Name:WENTHE, EUGENE E JR (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:E
Last Name:WENTHE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR STE 1E
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4505
Practice Address - Fax:321-409-6823
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061047207Q00000X
FLME117071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL020057300OtherBLACK LUNG
IL036061047OtherIL STATE LICENSE
IL08421024OtherBC/BS
IL170774OtherPERSONAL CARE
IL036061047Medicaid
IL054913OtherHEALTH ALLIANCE
IL101343OtherHEALTHLINK
IL6394POtherCATERPILLAR
ILCD7143OtherRR MEDICARE GROUP
IL080098256OtherRR MEDICARE PIN
IL133586700OtherACS-OWCP
IL14D0949277OtherCLIA
IL170774OtherPERSONAL CARE