Provider Demographics
NPI:1235128083
Name:WANTZ, MARK LYNWOOD (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LYNWOOD
Last Name:WANTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-0139
Mailing Address - Country:US
Mailing Address - Phone:304-872-5090
Mailing Address - Fax:304-872-0636
Practice Address - Street 1:350 FAIRVIEW HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1085
Practice Address - Country:US
Practice Address - Phone:304-872-5090
Practice Address - Fax:304-872-0636
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV15521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0052360000Medicaid
550775750OtherTAX ID NUMBER
WV0052360000Medicaid
550775750OtherTAX ID NUMBER