Provider Demographics
NPI:1891758462
Name:SEAN D WENGROFF, MD
Entity Type:Organization
Organization Name:SEAN D WENGROFF, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WENGROFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-935-5926
Mailing Address - Street 1:PO BOX 293869
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-3869
Mailing Address - Country:US
Mailing Address - Phone:409-935-5926
Mailing Address - Fax:409-935-5840
Practice Address - Street 1:6409 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-4017
Practice Address - Country:US
Practice Address - Phone:409-935-5926
Practice Address - Fax:409-935-5840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4167207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0099KPOtherBCBS
TX163371101Medicaid
TX0099KPOtherBCBS
TXH99244Medicare UPIN