Provider Demographics
NPI:1215981972
Name:WENNER, DONALD E (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:WENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1600 SE MAIN ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5423
Mailing Address - Country:US
Mailing Address - Phone:575-622-4374
Mailing Address - Fax:575-623-1161
Practice Address - Street 1:1600 SE MAIN ST
Practice Address - Street 2:SUITE F
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5423
Practice Address - Country:US
Practice Address - Phone:575-622-4374
Practice Address - Fax:575-623-1161
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM85-124208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35246Medicaid
NM2105060Medicare PIN
NM35246Medicaid