Provider Demographics
NPI:1073511408
Name:WENGLER, WALLACE EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:EDWARD
Last Name:WENGLER
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 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-5665
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:509 SE RIVERSIDE DR STE 200
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2579
Practice Address - Country:US
Practice Address - Phone:772-219-4026
Practice Address - Fax:772-219-0973
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0033979208600000X
FLME339792086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065625900Medicaid
FL065625900Medicaid