Provider Demographics
NPI:1831194315
Name:WENGROVITZ, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WENGROVITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5047 SHERRI ANN RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-6213
Mailing Address - Country:US
Mailing Address - Phone:210-237-4444
Mailing Address - Fax:210-828-5731
Practice Address - Street 1:9153 HUEBNER RD.
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1502
Practice Address - Country:US
Practice Address - Phone:210-614-7414
Practice Address - Fax:210-616-0509
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ72462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117279301Medicaid
TXWE081A614Medicare ID - Type Unspecified
TX117279301Medicaid