MEDICARE: WENDELL KOBLEGARD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	TRN7826	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053460378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDELL KOBLEGARD M.D.

Provider Business Mailing Address
First Line	:	2100 NEBRASKA AVE STE 113
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-5968
Country	:	US
Telephone Number	:	772-460-0321
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 NEBRASKA AVE STE 113
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-5968
Country	:	US
Telephone Number	:	772-460-0321
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	09/22/2011

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