Basic Information
| Provider Information | |||||||||
| NPI: | 1275573354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WENZKE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 VERNON PL STE 100 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137516667 | ||||||||
| FaxNumber: | 5138724553 | ||||||||
| Practice Location | |||||||||
| Address1: | 2990 MACK RD STE 107 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450145384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138604801 | ||||||||
| FaxNumber: | 5136824186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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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 | 207RG0100X | 35-084979 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2530890 | 05 | OH | MEDICAID |