Provider Demographics
NPI:1003838830
Name:HORACEK, MARILYN WENDT (DO)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:WENDT
Last Name:HORACEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:WENDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2115 CHAPLINE ST
Mailing Address - Street 2:STE 208
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3859
Mailing Address - Country:US
Mailing Address - Phone:304-217-3130
Mailing Address - Fax:304-217-3134
Practice Address - Street 1:2115 CHAPLINE ST
Practice Address - Street 2:STE 208
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3859
Practice Address - Country:US
Practice Address - Phone:304-217-3130
Practice Address - Fax:304-217-3134
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1551207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2057536Medicaid
080121554OtherRAILROAD MEDICARE
WV0055267000Medicaid
OH2057536Medicaid
G71378Medicare UPIN