Provider Demographics
NPI:1043501976
Name:WINGERTER, JACOB JOHN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:WINGERTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 MUELLER BLVD STE 3S.066C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3079
Mailing Address - Country:US
Mailing Address - Phone:406-868-9735
Mailing Address - Fax:
Practice Address - Street 1:4900 MUELLER BLVD STE 3S.066C
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:406-868-9735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0039540208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics