Healthcare Provider Details

I. General information

NPI: 1336751825
Provider Name (Legal Business Name): WENTWORTH DOUGLASS PHYSICIAN CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MEMBERS WAY FL 5
DOVER NH
03820-5933
US

IV. Provider business mailing address

PO BOX 412503
BOSTON MA
02241-2503
US

V. Phone/Fax

Practice location:
  • Phone: 603-609-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JOEL DEGENAARS
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 603-740-2806