Provider Demographics
NPI:1891724407
Name:WINGERT, JON MATHIAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MATHIAS
Last Name:WINGERT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2822 JACKSON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3497
Mailing Address - Country:US
Mailing Address - Phone:605-341-1208
Mailing Address - Fax:605-341-3552
Practice Address - Street 1:2822 JACKSON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3497
Practice Address - Country:US
Practice Address - Phone:605-341-1208
Practice Address - Fax:605-341-3552
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-01-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SD4903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5350060Medicaid
SD43-1812Medicare ID - Type Unspecified
SD5350060Medicaid