Provider Demographics
NPI:1245269786
Name:WENGER, THOMAS J (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:WENGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2090 AUSTIN HINES DR
Mailing Address - Street 2:
Mailing Address - City:CHINA SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:76633-3372
Mailing Address - Country:US
Mailing Address - Phone:254-296-8736
Mailing Address - Fax:254-867-1786
Practice Address - Street 1:1135 N LOOP 340
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705
Practice Address - Country:US
Practice Address - Phone:254-296-8736
Practice Address - Fax:254-897-1786
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY40006207Q00000X
TXD7362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000389486OtherANTHEM BCBS
KY31000458Medicaid
181835Medicare Oscar/Certification
B27492Medicare UPIN
KY31000458Medicaid