Provider Demographics
NPI:1336261437
Name:WENTWORTH, ROBERT DAVID (DPM)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DAVID
Last Name:WENTWORTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 S BETHLEHEM PIKE
Mailing Address - Street 2:C-1
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-5800
Mailing Address - Country:US
Mailing Address - Phone:215-836-0200
Mailing Address - Fax:
Practice Address - Street 1:602 S BETHLEHEM PIKE
Practice Address - Street 2:C-1
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-5800
Practice Address - Country:US
Practice Address - Phone:215-836-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003431L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1172476Medicaid
PA561243Medicare PIN
PAT89397Medicare UPIN