Healthcare Provider Details

I. General information

NPI: 1518999630
Provider Name (Legal Business Name): ROBERT JAMES WENZLER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 GOODMAN RD E SUITE D
SOUTHAVEN MS
38671-8824
US

IV. Provider business mailing address

928 GOODMAN RD E SUITE D
SOUTHAVEN MS
38671-8824
US

V. Phone/Fax

Practice location:
  • Phone: 662-470-4608
  • Fax: 662-470-4610
Mailing address:
  • Phone: 662-470-4608
  • Fax: 662-470-4610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM0000000655
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number80196
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: