Provider Demographics
NPI:1437384708
Name:WUNDERLICH, JACQUELINE E (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:E
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 GLESSNER AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2269
Mailing Address - Country:US
Mailing Address - Phone:419-526-8000
Mailing Address - Fax:419-526-8834
Practice Address - Street 1:199 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-0000
Practice Address - Country:US
Practice Address - Phone:419-342-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.120343207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology