Provider Demographics
NPI:1730505793
Name:WENGER, KRISTIN MARIE (DO)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:WENGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1120 POLARIS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-4042
Mailing Address - Country:US
Mailing Address - Phone:614-880-9333
Mailing Address - Fax:614-880-9331
Practice Address - Street 1:1604 WEDGEWOOD WAY
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1974
Practice Address - Country:US
Practice Address - Phone:614-406-3037
Practice Address - Fax:614-880-9331
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0232254Medicaid