Healthcare Provider Details

I. General information

NPI: 1225123797
Provider Name (Legal Business Name): DEBORAH WENKERT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 VISTA AVE
ST. LOUIS MO
63110
US

IV. Provider business mailing address

3691 RUTGER ST. PROVIDER ENROLLMENT
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6195
  • Fax: 314-977-8818
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number108299
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: