Provider Demographics
NPI:1659494334
Name:WENDEL, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WENDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:WENDEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3800 E JOHNSON AVE
Mailing Address - Street 2:STE E
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-1931
Mailing Address - Country:US
Mailing Address - Phone:870-932-0399
Mailing Address - Fax:870-932-0499
Practice Address - Street 1:3800 E JOHNSON AVE
Practice Address - Street 2:STE E
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-1931
Practice Address - Country:US
Practice Address - Phone:870-932-0399
Practice Address - Fax:870-932-0499
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
ARE-53592085R0204X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176716001Medicaid
AR5H437Medicare PIN