Provider Demographics
NPI:1538157383
Name:WENGER-KELLER, DAVID C (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:WENGER-KELLER
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 1:5409 AVENUE O
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113262207K00000X
OH35043843W207K00000X
IA25663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0240663Medicaid
A03112Medicare UPIN