Healthcare Provider Details

I. General information

NPI: 1699776591
Provider Name (Legal Business Name): MICHAEL SCOTT WENZEL M.D., F.A.A.F.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/13/2021
Certification Date: 06/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 FAIR LAKES PKWY KAISER PERMANENTE FAIR OAKS MEDICAL CENTER
FAIRFAX VA
22033-3952
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-934-5700
  • Fax: 703-934-5835
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1025416
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD039465
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101057449
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: