Provider Demographics
NPI:1184399339
Name:WENGRZYN, ERIC JAMES
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JAMES
Last Name:WENGRZYN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-2507
Mailing Address - Country:US
Mailing Address - Phone:434-390-8949
Mailing Address - Fax:
Practice Address - Street 1:2816 3RD ST SW
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33976-2507
Practice Address - Country:US
Practice Address - Phone:434-390-8949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW18238207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA