Healthcare Provider Details

I. General information

NPI: 1396206371
Provider Name (Legal Business Name): MARK ANTHONY WENDOLOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 SUMMAR DR
JACKSON TN
38301-3915
US

IV. Provider business mailing address

202 COUNT FLEET CT
MADISON AL
35756-4296
US

V. Phone/Fax

Practice location:
  • Phone: 731-423-1931
  • Fax:
Mailing address:
  • Phone: 670-790-4262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41411
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: