Provider Demographics
NPI:1376565382
Name:WHEAT, WENDELL T (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:T
Last Name:WHEAT
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 1:6005 PARK AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5216
Mailing Address - Country:US
Mailing Address - Phone:901-680-9205
Mailing Address - Fax:901-821-0078
Practice Address - Street 1:6005 PARK AVE STE 601
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5216
Practice Address - Country:US
Practice Address - Phone:901-680-9205
Practice Address - Fax:901-821-0078
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000009011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3179000Medicare ID - Type Unspecified
TNB03844Medicare UPIN