Provider Demographics
NPI:1740494244
Name:WELLENDORF ENT, P.C.
Entity type:Organization
Organization Name:WELLENDORF ENT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WELLENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-792-4368
Mailing Address - Street 1:PO BOX 766
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-0766
Mailing Address - Country:US
Mailing Address - Phone:712-792-4368
Mailing Address - Fax:712-792-4351
Practice Address - Street 1:405 S CLARK ST
Practice Address - Street 2:SUITE 215
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3065
Practice Address - Country:US
Practice Address - Phone:712-792-4368
Practice Address - Fax:712-792-2056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30594207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2124032Medicaid
IA1124032Medicaid
IA5124032Medicaid
IA3124032Medicaid
IA6124032Medicaid
IA3124032Medicaid
IA2124032Medicaid