Provider Demographics
NPI:1508820598
Name:WENICK, ROBERT LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:WENICK
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 1:2 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-2100
Mailing Address - Country:US
Mailing Address - Phone:203-791-2221
Mailing Address - Fax:203-791-0682
Practice Address - Street 1:2 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-2100
Practice Address - Country:US
Practice Address - Phone:203-791-2221
Practice Address - Fax:203-791-0682
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B83875Medicare UPIN
110006211Medicare ID - Type Unspecified