Provider Demographics
NPI:1083709471
Name:BLUMBERG, WENDY L (MD)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:BLUMBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 DELCO PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420
Mailing Address - Country:US
Mailing Address - Phone:937-299-2587
Mailing Address - Fax:937-299-0124
Practice Address - Street 1:1775 DELCO PARK DRIVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420
Practice Address - Country:US
Practice Address - Phone:937-299-2587
Practice Address - Fax:937-299-0124
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.077984208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2260333Medicaid