Provider Demographics
NPI:1770664732
Name:WIESENTHAL, MARTIN JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JEROME
Last Name:WIESENTHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8038 WURZBACH RD
Mailing Address - Street 2:STE 320
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3813
Mailing Address - Country:US
Mailing Address - Phone:210-614-3365
Mailing Address - Fax:210-615-3757
Practice Address - Street 1:8038 WURZBACH RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3817
Practice Address - Country:US
Practice Address - Phone:210-614-3365
Practice Address - Fax:210-615-3757
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4763207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122768806Medicaid
TXP00175620OtherMEDICARE RAILROAD
TX8F10093Medicare PIN
TX122768806Medicaid