Provider Demographics
NPI:1982603379
Name:WENZKE, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:WENZKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2731
Mailing Address - Country:US
Mailing Address - Phone:937-223-4461
Mailing Address - Fax:937-224-1945
Practice Address - Street 1:122 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2731
Practice Address - Country:US
Practice Address - Phone:937-223-4461
Practice Address - Fax:937-224-1945
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-048670207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000005831OtherANTHEM
OH0572367Medicaid
OH0554246Medicare PIN
OH000000005831OtherANTHEM