Provider Demographics
NPI:1730128257
Name:WENNEKER, MARK B (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:WENNEKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LOMBARD STREET
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-893-2645
Mailing Address - Fax:
Practice Address - Street 1:1800 LOMBARD STREET
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146
Practice Address - Country:US
Practice Address - Phone:215-893-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013472208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101488671Medicaid
NJ0192015Medicaid
I49360Medicare UPIN
NJ0192015Medicaid