Provider Demographics
NPI:1346261690
Name:WENTZ, ROBERT M (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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:PO BOX 602573
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2573
Mailing Address - Country:US
Mailing Address - Phone:864-427-9045
Mailing Address - Fax:864-427-8826
Practice Address - Street 1:429 E MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-1902
Practice Address - Country:US
Practice Address - Phone:864-427-9045
Practice Address - Fax:864-427-8826
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC048950Medicaid
SCSC68725019Medicare PIN
SC048950Medicaid