Provider Demographics
NPI:1457332793
Name:WENKSTERN, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:WENKSTERN
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 1:1100 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-3225
Mailing Address - Country:US
Mailing Address - Phone:276-638-2354
Mailing Address - Fax:276-638-3398
Practice Address - Street 1:1100 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3225
Practice Address - Country:US
Practice Address - Phone:276-638-2354
Practice Address - Fax:276-638-3398
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035460207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA065845OtherBC
NC5901472Medicaid
VA006443257Medicaid
NC5901472Medicaid
VA200000054Medicare ID - Type Unspecified