Provider Demographics
NPI:1013165356
Name:MARTIN J. WIESENTHAL, MD, PA
Entity Type:Organization
Organization Name:MARTIN J. WIESENTHAL, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WIESENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-614-3365
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78291-0066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8038 WURZBACH RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3817
Practice Address - Country:US
Practice Address - Phone:210-614-3365
Practice Address - Fax:210-615-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-28
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4763207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219489601Medicaid
TX0A3113Medicare PIN
TX219489601Medicaid