Provider Demographics
NPI:1992915623
Name:WENCKUS, DALIA JEANETTE (MD)
Entity type:Individual
Prefix:
First Name:DALIA
Middle Name:JEANETTE
Last Name:WENCKUS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 19TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1831
Mailing Address - Country:US
Mailing Address - Phone:865-331-2020
Mailing Address - Fax:
Practice Address - Street 1:501 19TH ST STE 401
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1831
Practice Address - Country:US
Practice Address - Phone:865-331-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0064268207VM0101X
MT40862207VM0101X
OH35.126718207VM0101X
IN01063635A207VM0101X
TN72651207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ100660Medicaid