MEDICARE: MICHAEL KEITH WENSLEY MD INC A MEDICAL CORPORATION

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	174400000X	Specialist	G78267	CA

General Provider Information

NPI Number	:	1861721250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL KEITH WENSLEY MD INC A MEDICAL CORPORATION

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	:	949-467-9081
Fax Number	:	209-203-1036

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	:	949-467-9081
Fax Number	:	714-429-1685

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL K WENSLEY
Credential	:	MD
Telephone Number	:	949-705-8226

Provider Enumeration Date	:	12/14/2009
Last Update Date	:	08/16/2024

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