Provider Demographics
NPI:1598030025
Name:WENTZELL, FERNALD WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNALD
Middle Name:WILLIAM
Last Name:WENTZELL
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 1:5407 LINEA DEL CIELO
Mailing Address - Street 2:PO BOX 397
Mailing Address - City:RANCHO SANTA FE,
Mailing Address - State:CA
Mailing Address - Zip Code:92067
Mailing Address - Country:US
Mailing Address - Phone:858-756-4084
Mailing Address - Fax:858-756-1246
Practice Address - Street 1:5407 LINEA DEL CIELO
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA FE,
Practice Address - State:CA
Practice Address - Zip Code:92067
Practice Address - Country:US
Practice Address - Phone:858-756-4084
Practice Address - Fax:858-756-1246
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36925174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist