MEDICARE: WENSLEY M KEITH MD PC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1174357768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WENSLEY M KEITH MD PC

Provider Business Mailing Address
First Line	:	1601 DOVE ST STE 170
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-1421
Country	:	US
Telephone Number	:	949-610-5240
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 DOVE ST STE 170
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-1421
Country	:	US
Telephone Number	:	949-610-5240
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TAMMY KNICKERBOCKER
Credential	:
Telephone Number	:	949-610-5240

Provider Enumeration Date	:	08/27/2024
Last Update Date	:	05/28/2025

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