Provider Demographics
NPI:1881861326
Name:WENTWORTH, JUSTIN RAY (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RAY
Last Name:WENTWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:520 JEFFERSON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2538
Mailing Address - Country:US
Mailing Address - Phone:724-527-8060
Mailing Address - Fax:724-522-4002
Practice Address - Street 1:8775 NORWIN AVE
Practice Address - Street 2:
Practice Address - City:NORTH HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642-2718
Practice Address - Country:US
Practice Address - Phone:724-850-6933
Practice Address - Fax:724-832-4297
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS014539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102699705Medicaid
PA102699705Medicaid