Provider Demographics
NPI:1194861740
Name:WENNEKER, MARK B (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:WENNEKER
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 1:223 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-2422
Mailing Address - Country:US
Mailing Address - Phone:617-480-5049
Mailing Address - Fax:
Practice Address - Street 1:223 UPLAND RD
Practice Address - Street 2:
Practice Address - City:NEWTONVILLE
Practice Address - State:MA
Practice Address - Zip Code:02460-2422
Practice Address - Country:US
Practice Address - Phone:617-480-5049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58179207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine