Basic Information
| Provider Information | |||||||||
| NPI: | 1174692933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENTZ | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10335 N PORT WASHINGTON RD | ||||||||
| Address2: | 250 | ||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530925763 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 411 HAMILTON BLVD | ||||||||
| Address2: | 1824 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616021144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094949320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.