Healthcare Provider Details

I. General information

NPI: 1699792226
Provider Name (Legal Business Name): CHARLES WILLIAM WENTWORTH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 TERRITORIAL RD W
BATTLE CREEK MI
49015-3245
US

IV. Provider business mailing address

359 TERRITORIAL RD W
BATTLE CREEK MI
49015-3245
US

V. Phone/Fax

Practice location:
  • Phone: 269-968-6353
  • Fax:
Mailing address:
  • Phone: 269-968-6353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901000996
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: