Provider Demographics
NPI:1689670580
Name:JAGGERNAUTH, WAINWRIGHT ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:WAINWRIGHT
Middle Name:ANTHONY
Last Name:JAGGERNAUTH
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 1:433 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1690
Mailing Address - Country:US
Mailing Address - Phone:419-636-1131
Mailing Address - Fax:419-636-3100
Practice Address - Street 1:524 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1618
Practice Address - Country:US
Practice Address - Phone:419-636-9800
Practice Address - Fax:419-636-0451
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010939742085R0001X
NY0020012085R0001X
OH35.0930442085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02460520Medicaid
MI1689670580OtherMI MEDICAID-OH LOCATIONS
MI1689670580Medicaid
OH2949920Medicaid
OHP00746491OtherRR MEDICARE
MI0N24000021Medicare PIN
NYH95121Medicare UPIN
OHP00746491OtherRR MEDICARE