Provider Demographics
NPI:1922595131
Name:WINGARD, DORIAN L (MPA)
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:L
Last Name:WINGARD
Suffix:
Gender:M
Credentials:MPA
Other - Prefix:
Other - First Name:DORIAN
Other - Middle Name:L
Other - Last Name:WINGARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:4021 GALLATIN DR
Mailing Address - Street 2:
Mailing Address - City:OBETZ
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4387
Mailing Address - Country:US
Mailing Address - Phone:614-439-2808
Mailing Address - Fax:
Practice Address - Street 1:4021 GALLATIN DR
Practice Address - Street 2:
Practice Address - City:OBETZ
Practice Address - State:OH
Practice Address - Zip Code:43207-4387
Practice Address - Country:US
Practice Address - Phone:614-439-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 251300000X, 251K00000X, 261QB0400X, 261QC1500X, 374J00000X
OH172V00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker
No251300000XAgenciesLocal Education Agency (LEA)
No251K00000XAgenciesPublic Health or Welfare
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1790272953Medicaid