Provider Demographics
NPI:1689673188
Name:WENTZ, RALPH J (DPM)
Entity Type:Individual
Prefix:DR
First Name:RALPH
Middle Name:J
Last Name:WENTZ
Suffix:
Gender:M
Credentials:DPM
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 456
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-0456
Mailing Address - Country:US
Mailing Address - Phone:719-539-6600
Mailing Address - Fax:719-539-6606
Practice Address - Street 1:920 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9669
Practice Address - Country:US
Practice Address - Phone:719-539-6600
Practice Address - Fax:719-539-6606
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPOD.0000429213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01004290Medicaid
CO1045130002Medicare NSC
CO01004290Medicaid
COC54473Medicare PIN