Provider Demographics
NPI:1578759379
Name:KENT WENGER MD PA
Entity Type:Organization
Organization Name:KENT WENGER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-333-1109
Mailing Address - Street 1:310 NW 76TH DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1593
Mailing Address - Country:US
Mailing Address - Phone:352-333-1109
Mailing Address - Fax:352-331-6323
Practice Address - Street 1:310 NW 76TH DR
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1593
Practice Address - Country:US
Practice Address - Phone:352-333-1109
Practice Address - Fax:352-331-6323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-15
Last Update Date:2007-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME865592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8177Medicare PIN