Provider Demographics
NPI:1639270069
Name:WENTWORTH, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:WENTWORTH
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 1:415 JEFFERSON ST NORTH
Mailing Address - Street 2:TRI-COUNTY HEALTH CARE
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1296
Mailing Address - Country:US
Mailing Address - Phone:218-631-3510
Mailing Address - Fax:218-631-7507
Practice Address - Street 1:1027 WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274948Medicaid
MNHP42348OtherHEALTHPARTNERS
MN074M7WEOtherBCBS
MN1031036OtherPREFERREDONE
MN01-14159OtherMEDICA
NE41091744413Medicaid
WI82362200Medicaid
ND11772Medicaid
MN256961200Medicaid
MN169526OtherUCAREMN
NE41091744413Medicaid
MN01-14159OtherMEDICA
MN169526OtherUCAREMN
MN256961200Medicaid