Healthcare Provider Details

I. General information

NPI: 1336139666
Provider Name (Legal Business Name): MARK A WENGER M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 PARK HILL DR
FREDERICKSBURG VA
22401-3377
US

IV. Provider business mailing address

DEPT. 453 PO BOX 1000
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-5660
  • Fax: 540-372-6920
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0101059064
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: