Provider Demographics
NPI:1720576432
Name:WENGER, JUSTIN BLAIR (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BLAIR
Last Name:WENGER
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 1:4037 NW 86TH TER RM 3154
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-9277
Mailing Address - Country:US
Mailing Address - Phone:352-294-4945
Mailing Address - Fax:
Practice Address - Street 1:4037 NW 86TH TER RM 3154
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-9277
Practice Address - Country:US
Practice Address - Phone:352-294-4945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program