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General NPI Number Information
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NPI Number | 1902084783
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Entity Type | Organization
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Legal Business Name | WENDELL MARK STREET, M.D., INC
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Dates
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Enumeration Date | 02/04/2008
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Last Update Date | 02/04/2008
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Provider Practice Location Address
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Address Line | 11332 MOUNTAIN VIEW AVE SUITE A
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City | LOMA LINDA
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State | CA
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Zip | 92354-3854
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Country | US
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Telephone | 951-640-1230
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Fax | 951-924-2535
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Provider Business Mailing Address
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Address Line | 17868 US HIGHWAY 18
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City | APPLE VALLEY
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State | CA
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Zip | 92307-1267
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Country | US
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Telephone | 951-640-1230
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Fax | 951-924-2535
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Authorized Official
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Title or Position | OWNER/MEDICAL DIRECTOR
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Name | DR. WENELL MARK STREET
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Credential | M.D.
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Telephone | 951-640-1230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | A43837
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License Number State | CA
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