Provider Demographics
NPI:1083840524
Name:WYNES, JACOB (DPM)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WYNES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 KERNAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207
Mailing Address - Country:US
Mailing Address - Phone:410-448-7112
Mailing Address - Fax:
Practice Address - Street 1:2200 KERNAN DRIVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207
Practice Address - Country:US
Practice Address - Phone:410-448-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDO1555213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery