Provider Demographics
NPI:1760690713
Name:WINEMAN, ROBERT WADE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WADE
Last Name:WINEMAN
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 55769
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-5769
Mailing Address - Country:US
Mailing Address - Phone:601-200-6162
Mailing Address - Fax:
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:877-406-2916
Practice Address - Fax:601-682-7909
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012378412085R0202X
MS205442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00752697OtherRAILROAD MEDICARE
P00752697OtherRAILROAD MEDICARE