Provider Demographics
NPI:1245069277
Name:K. WENSLEY. MICHAEL MD, PC
Entity type:Organization
Organization Name:K. WENSLEY. MICHAEL MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KNICKERBOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:OTHER
Authorized Official - Phone:949-467-9081
Mailing Address - Street 1:1601 DOVE ST STE 170
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1421
Mailing Address - Country:US
Mailing Address - Phone:949-674-9081
Mailing Address - Fax:209-203-1036
Practice Address - Street 1:1601 DOVE ST STE 170
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1421
Practice Address - Country:US
Practice Address - Phone:949-674-9081
Practice Address - Fax:209-203-1036
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL KEITH WENSLEY MD INC A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-29
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty