Healthcare Provider Details

I. General information

NPI: 1841478625
Provider Name (Legal Business Name): PAUL DOUGLAS WENTLAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 TOMBRAS AVE
EAST RIDGE TN
37412-2720
US

IV. Provider business mailing address

1508 TOMBRAS AVE
EAST RIDGE TN
37412-2720
US

V. Phone/Fax

Practice location:
  • Phone: 423-867-4969
  • Fax: 423-867-4971
Mailing address:
  • Phone: 423-867-4969
  • Fax: 423-867-4971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40539
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number74929
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: