MEDICARE: GREGG WENTWORTH O.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	152W00000X	Optometrist	4363	TX

General Provider Information

NPI Number	:	1770552887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGG WENTWORTH O.D.

Provider Business Mailing Address
First Line	:	8831 FEATHER TRL
Second Line	:
City	:	HELOTES
State	:	TX
Zip	:	78023-4486
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5788 ECKHERT RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-3900
Country	:	US
Telephone Number	:	210-699-2113
Fax Number	:

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/09/2007

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