Provider Demographics
NPI:1063595601
Name:WENECK, BRUCE EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:EDWARD
Last Name:WENECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MEMORIAL BLVD W
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6219
Mailing Address - Country:US
Mailing Address - Phone:301-791-7060
Mailing Address - Fax:301-791-8990
Practice Address - Street 1:303 MEMORIAL BLVD W
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6219
Practice Address - Country:US
Practice Address - Phone:301-791-7060
Practice Address - Fax:301-791-8990
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0022698208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE57291Medicare UPIN