Provider Demographics
NPI:1902844756
Name:YNGSTROM, JEFFREY A (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:YNGSTROM
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 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-484-0850
Mailing Address - Fax:260-484-5919
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4731
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052614A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5652OtherPHP
MI4218292100Medicaid
OH2178709Medicaid
IN000000092598OtherANTHEM
IN191150AMedicare ID - Type Unspecified
IN925240XMedicare ID - Type Unspecified
IN924750IMedicare ID - Type Unspecified
IN190320VMedicare ID - Type Unspecified
IN055740ZMedicare ID - Type Unspecified
OH2178709Medicaid
IN000000092598OtherANTHEM
MI4218292100Medicaid
IN147380WMedicare ID - Type Unspecified
OHYN4111571Medicare ID - Type Unspecified