Provider Demographics
NPI:1518999630
Name:WENZLER, ROBERT JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAMES
Last Name:WENZLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 GOODMAN RD E
Mailing Address - Street 2:SUITE D
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8824
Mailing Address - Country:US
Mailing Address - Phone:662-470-4608
Mailing Address - Fax:662-470-4610
Practice Address - Street 1:928 GOODMAN RD E
Practice Address - Street 2:SUITE D
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8824
Practice Address - Country:US
Practice Address - Phone:662-470-4608
Practice Address - Fax:662-470-4610
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000655213E00000X
MS80196213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00464002OtherMEDICARE ID TYPE UNSPECIFIED
TN3350010Medicare PIN
3350010Medicare PIN