Healthcare Provider Details

I. General information

NPI: 1538157383
Provider Name (Legal Business Name): DAVID C WENGER-KELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

IV. Provider business mailing address

5409 AVENUE O
FORT MADISON IA
52627-9601
US

V. Phone/Fax

Practice location:
  • Phone: 319-376-2134
  • Fax: 319-376-2188
Mailing address:
  • Phone: 319-376-2134
  • Fax: 319-376-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036113262
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number35043843W
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25663
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: