Provider Demographics
NPI:1598792020
Name:WENBERG, KENNETH FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:FRED
Last Name:WENBERG
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:HEPPNER
Mailing Address - State:OR
Mailing Address - Zip Code:97836-0009
Mailing Address - Country:US
Mailing Address - Phone:541-676-2942
Mailing Address - Fax:541-676-2901
Practice Address - Street 1:274 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:HEPPNER
Practice Address - State:OR
Practice Address - Zip Code:97836
Practice Address - Country:US
Practice Address - Phone:541-676-5440
Practice Address - Fax:541-676-8036
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14131207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130039Medicaid
ORH22767Medicare ID - Type Unspecified
OR130039Medicaid