Provider Demographics
NPI:1902084783
Name:WENDELL MARK STREET, M.D., INC
Entity Type:Organization
Organization Name:WENDELL MARK STREET, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WENELL
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-640-1230
Mailing Address - Street 1:17868 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1267
Mailing Address - Country:US
Mailing Address - Phone:951-640-1230
Mailing Address - Fax:951-924-2535
Practice Address - Street 1:11332 MOUNTAIN VIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3854
Practice Address - Country:US
Practice Address - Phone:951-640-1230
Practice Address - Fax:951-924-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43837207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty