Provider Demographics
NPI:1750467973
Name:WINGATE, KATHERINE HOLLIS (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:HOLLIS
Last Name:WINGATE
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 1:9000 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 332
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1185
Mailing Address - Country:US
Mailing Address - Phone:937-832-7337
Mailing Address - Fax:937-832-4817
Practice Address - Street 1:9000 NORTH MAIN STREET
Practice Address - Street 2:SUITE 332
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1185
Practice Address - Country:US
Practice Address - Phone:937-832-7337
Practice Address - Fax:937-832-4817
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350661792080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000037310OtherBLUE CROSS BLUE SHIELD
0958076OtherBUREAU FOR CHILDREN WITH
OH0958076Medicaid
1220398OtherUNITED HEALTHCARE
311627276039OtherCARESOURCE
0637490OtherAETNA