Provider Demographics
NPI:1063502912
Name:GROGAN, WENDELL A (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:A
Last Name:GROGAN
Suffix:
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:PO BOX 9547
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9547
Mailing Address - Country:US
Mailing Address - Phone:281-359-5981
Mailing Address - Fax:281-359-3591
Practice Address - Street 1:22999 HIGHWAY 59 N STE 416
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-4412
Practice Address - Country:US
Practice Address - Phone:281-359-5981
Practice Address - Fax:281-359-3591
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM07402084S0012X, 2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1590675OtherFIRST HEALTH
TX0026MHOtherBLUE CROSS BLUE SHIELD
TX6700232OtherCIGNA
TX172034401Medicaid
TX635873OtherMHHNP
TX4462988OtherAETNA
TX1590675OtherFIRST HEALTH
TXB41637Medicare UPIN
TX4462988OtherAETNA
TXDD0999Medicare PIN
TXP00656931Medicare PIN