Provider Demographics
NPI:1023090230
Name:WYNBERG, JASON B (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:B
Last Name:WYNBERG
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 1:3 UNIVERSITY PLZ STE 205
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-6208
Mailing Address - Country:US
Mailing Address - Phone:201-833-3599
Mailing Address - Fax:201-227-6207
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4245
Practice Address - Country:US
Practice Address - Phone:201-227-6008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086135208800000X
NJBW9323382208800000X
NY240026208800000X
NJ25MA10611400208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPENDINGMedicaid
NY02759039Medicaid
NJP1388005OtherOXFORD
I35111Medicare UPIN