Provider Demographics
NPI:1437240314
Name:STREET, WENDELL MARK (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:MARK
Last Name:STREET
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 1:109 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-2157
Mailing Address - Country:US
Mailing Address - Phone:951-273-1000
Mailing Address - Fax:951-273-1090
Practice Address - Street 1:14075 HESPERIA RD
Practice Address - Street 2:SUITE 205
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4500
Practice Address - Country:US
Practice Address - Phone:760-596-3708
Practice Address - Fax:760-596-3731
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43837207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330619189OtherFEDERAL TAX ID
CA330619189OtherFEDERAL TAX ID
CA00A438370Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID