Provider Demographics
NPI:1598107641
Name:D. E. WENNER III, M.D., P.C.
Entity Type:Organization
Organization Name:D. E. WENNER III, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WENNER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:1575-623-1980
Mailing Address - Street 1:1600 SE MAIN ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5423
Mailing Address - Country:US
Mailing Address - Phone:575-623-1980
Mailing Address - Fax:
Practice Address - Street 1:1600 SE MAIN ST
Practice Address - Street 2:SUITE F
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5423
Practice Address - Country:US
Practice Address - Phone:575-623-1980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-0816208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty