Provider Demographics
NPI:1043273873
Name:WENGROFF, SEAN DARYL (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DARYL
Last Name:WENGROFF
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 1:540 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:TX
Mailing Address - Zip Code:79045-2820
Mailing Address - Country:US
Mailing Address - Phone:806-364-7512
Mailing Address - Fax:806-349-5652
Practice Address - Street 1:540 W 15TH ST
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:TX
Practice Address - Zip Code:79045
Practice Address - Country:US
Practice Address - Phone:806-364-7512
Practice Address - Fax:806-349-5652
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4167208M00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163758901Medicaid
TX8K4080OtherBCBS
TXH99244Medicare UPIN