Provider Demographics
NPI:1275598468
Name:KITCHENS, WENTZELLE KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:WENTZELLE
Middle Name:KIM
Last Name:KITCHENS
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 1:501 SPARTA RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1371
Mailing Address - Country:US
Mailing Address - Phone:478-552-0001
Mailing Address - Fax:
Practice Address - Street 1:501 SPARTA RD
Practice Address - Street 2:SUITE F
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1371
Practice Address - Country:US
Practice Address - Phone:478-552-0001
Practice Address - Fax:478-552-0048
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038277207R00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110083260OtherRAILROAD MEDICARE
GA00597605BMedicaid
GA476142OtherBCBS
GA00597605AMedicaid
GA00597605BMedicaid
GA476142OtherBCBS
GA11BDHBKMedicare ID - Type Unspecified