Basic Information
| Provider Information | |||||||||
| NPI: | 1265709315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENZEL | ||||||||
| FirstName: | MARC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 RIO GRANDE ST | ||||||||
| Address2: | SUITE 415 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
| FaxNumber: | 5123248962 | ||||||||
| Practice Location | |||||||||
| Address1: | 5103 KYLE CENTER DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | KYLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786406163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125510855 | ||||||||
| FaxNumber: | 5125510856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2011 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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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 | 207RE0101X | J1426 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 114934604 | 05 | TX | MEDICAID |