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General NPI Number Information
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NPI Number | 1528057387
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Entity Type | Individual
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Provider Name | TRACEY G WELLENDORF MD
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Gender | Male
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Dates
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Enumeration Date | 10/14/2005
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Last Update Date | 03/25/2019
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Provider Practice Location Address
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Address Line | 405 S CLARK ST SUITE 215
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City | CARROLL
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State | IA
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Zip | 51401-3065
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Country | US
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Telephone | 712-792-4368
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Fax | 712-792-2056
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Provider Business Mailing Address
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Address Line | PO BOX 766
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City | CARROLL
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State | IA
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Zip | 51401-0766
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Country | US
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Telephone | 712-792-4368
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Fax | 712-792-4351
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 30594
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License Number State | IA
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