Provider Demographics
NPI:1558682815
Name:WENTLAND, CARISSA JANE (DO)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:JANE
Last Name:WENTLAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 BEAUBIEN ST # 3515
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-745-9049
Mailing Address - Fax:313-993-3879
Practice Address - Street 1:3901 BEAUBIEN ST # 3515
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-9049
Practice Address - Fax:313-993-3879
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019020869207Y00000X
MI5101018847207YX0905X
MI5101025549207YP0228X
OH01220207Y00000X
MA262814207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA262814Medicaid
MA1558682815Medicaid
MA1558682815Medicaid
MA1558682815Medicare Oscar/Certification
MA1558682815Medicare NSC
MA1558682815Medicare PIN
MA1558682815Medicare UPIN
MA262814Medicaid
MA262814Medicare Oscar/Certification