MEDICARE: SEAN D WENGROFF, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	L4167	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0099KP	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891758462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAN D WENGROFF, MD

Provider Business Mailing Address
First Line	:	PO BOX 293869
Second Line	:
City	:	KERRVILLE
State	:	TX
Zip	:	78029-3869
Country	:	US
Telephone Number	:	409-935-5926
Fax Number	:	409-935-5840

Provider Business Practice Location Address
First Line	:	6409 MEMORIAL DR
Second Line	:
City	:	TEXAS CITY
State	:	TX
Zip	:	77591-4017
Country	:	US
Telephone Number	:	409-935-5926
Fax Number	:	409-935-5840

Authorized Official
Title or Position	:	OWNER
Name	:	SEAN D WENGROFF
Credential	:	MD
Telephone Number	:	409-935-5926

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	10/23/2012

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