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General NPI Number Information
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NPI Number | 1861788937
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Entity Type | Individual
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Provider Name | JACOB WILLIAM WENDLING D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/27/2011
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Last Update Date | 08/29/2024
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Provider Practice Location Address
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Address Line | 3200 CHANNING WAY STE 205
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7546
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Country | US
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Telephone | 208-535-4580
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Fax | 208-535-4520
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Provider Business Mailing Address
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Address Line | PO BOX 277381
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City | ATLANTA
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State | GA
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Zip | 30384-7381
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Country | US
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Telephone |
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Fax |
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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 | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 0-1292
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License Number State | ID
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