Provider Demographics
NPI:1437143971
Name:WENZEL, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:WENZEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:224 D CORNWALL STREET NW
Mailing Address - Street 2:STE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:205 E. HIRST ROAD, SUITE 200
Practice Address - Street 2:
Practice Address - City:PURCELLVILLE
Practice Address - State:VA
Practice Address - Zip Code:20132-6199
Practice Address - Country:US
Practice Address - Phone:540-338-6101
Practice Address - Fax:540-338-7803
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1437143971Medicaid
VA30016052980001Medicaid
P00174012OtherRR MEDICARE
VA010086779Medicaid