Provider Demographics
NPI:1952470841
Name:WENTZEL, PETER V (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:V
Last Name:WENTZEL
Suffix:
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:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26410-0035
Mailing Address - Country:US
Mailing Address - Phone:304-892-2828
Mailing Address - Fax:304-892-2927
Practice Address - Street 1:725 NORTH PIKE STREET
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1270
Practice Address - Country:US
Practice Address - Phone:304-265-4909
Practice Address - Fax:304-265-4915
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007172Medicaid
WV2028151Medicare PIN
WVP00352858Medicare PIN
WV3810007172Medicaid