Provider Demographics
NPI:1962504415
Name:WIANT, MAX KENNETH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:KENNETH
Last Name:WIANT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KEN
Other - Middle Name:
Other - Last Name:WIANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4625 ALABAMA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79930-2517
Mailing Address - Country:US
Mailing Address - Phone:915-564-0411
Mailing Address - Fax:915-562-5303
Practice Address - Street 1:4625 ALABAMA ST
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79930-2517
Practice Address - Country:US
Practice Address - Phone:915-564-0411
Practice Address - Fax:915-562-5303
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8733207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine