Provider Demographics
NPI:1861721250
Name:MICHAEL KEITH WENSLEY MD INC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:MICHAEL KEITH WENSLEY MD INC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:WENSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-705-8226
Mailing Address - Street 1:1601 DOVE ST STE 170
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1421
Mailing Address - Country:US
Mailing Address - Phone:949-467-9081
Mailing Address - Fax:209-203-1036
Practice Address - Street 1:1601 DOVE ST STE 170
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1421
Practice Address - Country:US
Practice Address - Phone:949-467-9081
Practice Address - Fax:714-429-1685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty