Provider Demographics
NPI:1962493908
Name:WARDNER, JON MASTER (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MASTER
Last Name:WARDNER
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 1:5333 MCAULEY DR
Mailing Address - Street 2:SUITE R2009
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1014
Mailing Address - Country:US
Mailing Address - Phone:734-712-0050
Mailing Address - Fax:734-712-0055
Practice Address - Street 1:5333 MCAULEY DR
Practice Address - Street 2:SUITE R2009
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1014
Practice Address - Country:US
Practice Address - Phone:734-712-0050
Practice Address - Fax:734-712-0055
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW407403208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI250H110020OtherBCBS OF MICHIGAN
MI2713472Medicaid
MI250007537OtherRAILROAD MEDICARE
MIE49381Medicare UPIN
MI0N12520002Medicare ID - Type UnspecifiedMEDICARE COMMON PROVIDER
MI250H110020OtherBCBS OF MICHIGAN