Provider Demographics
NPI:1861494502
Name:WENTZKY, JOSEPH HAROLD JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:HAROLD
Last Name:WENTZKY
Suffix:JR
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:340 MEDICAL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2441
Practice Address - Country:US
Practice Address - Phone:864-797-9400
Practice Address - Fax:864-797-9402
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10427208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104274Medicaid
SC576007863006OtherBCBS
SCP00615797OtherRAILROAD MEDICARE
SCP00801272OtherRR MEDICARE
SCP00615797OtherRAILROAD MEDICARE
SCC610187951Medicare PIN
SCP00801272OtherRR MEDICARE