Provider Demographics
NPI:1326077256
Name:WESSEL, LOREN SCOTT (DPM)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:SCOTT
Last Name:WESSEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 S 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6080
Mailing Address - Country:US
Mailing Address - Phone:520-882-7009
Mailing Address - Fax:520-882-5227
Practice Address - Street 1:3722 S 16TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6080
Practice Address - Country:US
Practice Address - Phone:520-882-7009
Practice Address - Fax:520-882-5227
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDPM0367213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ075954Medicaid
AZDPM0367OtherSTATE LICENSE #
AZAZ0191030OtherBCBS PROVIDER ID #
AZ075954Medicaid
AZ0843820001Medicare NSC
AZZDPM367Medicare ID - Type UnspecifiedMEDICARE ID NUMBER