Provider Demographics
NPI:1508840109
Name:WURTH, JASON THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:THEODORE
Last Name:WURTH
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-1850
Mailing Address - Fax:605-328-1855
Practice Address - Street 1:3401 W 49TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-2322
Practice Address - Country:US
Practice Address - Phone:605-328-1850
Practice Address - Fax:605-328-1855
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44169OtherLICENSE
WIG35098Medicare UPIN
WI072900040Medicare Oscar/Certification
WI075100035Medicare Oscar/Certification
WI072250043Medicare Oscar/Certification
WI000009Medicare Oscar/Certification