Provider Demographics
NPI:1083658298
Name:WENTZ, BROCK T (MD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:T
Last Name:WENTZ
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 1:1800 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-383-2000
Mailing Address - Fax:
Practice Address - Street 1:2231 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-383-2663
Practice Address - Fax:702-383-2682
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007014767207XX0801X
CAA108401207XX0801X
NV15016207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV115125Medicare PIN
NVV107081Medicare PIN