Healthcare Provider Details

I. General information

NPI: 1306965504
Provider Name (Legal Business Name): DAVID C. WENGER-KELLER, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O SUITE 103
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

5409 AVENUE O SUITE 103
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-372-6280
  • Fax: 319-372-8119
Mailing address:
  • Phone: 319-372-6280
  • Fax: 319-372-8119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25663
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0790337
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier0298828
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DR. DAVID WENGER-KELLER
Title or Position: OWNER
Credential: MD
Phone: 319-372-6280