Healthcare Provider Details

I. General information

NPI: 1457332793
Provider Name (Legal Business Name): MICHAEL G WENKSTERN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E CHURCH ST
MARTINSVILLE VA
24112-3225
US

IV. Provider business mailing address

1100 E CHURCH ST
MARTINSVILLE VA
24112-3225
US

V. Phone/Fax

Practice location:
  • Phone: 276-638-2354
  • Fax: 276-638-3398
Mailing address:
  • Phone: 276-638-2354
  • Fax: 276-638-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101035460
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: