Provider Demographics
NPI:1710113402
Name:DINGWALL, JESSIKA SILVIA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSIKA
Middle Name:SILVIA
Last Name:DINGWALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3851 ROGER BROOKE DR
Mailing Address - Street 2:MCHE-QD (CREDS)
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5868
Practice Address - Country:US
Practice Address - Phone:307-350-8577
Practice Address - Fax:307-875-8800
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012482072085R0202X
WYTL33832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology