Provider Demographics
NPI:1295738797
Name:WINGERSON, ERIC A (DO)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:WINGERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 E 17TH ST
Mailing Address - Street 2:ST. #4
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6493
Mailing Address - Country:US
Mailing Address - Phone:208-524-3939
Mailing Address - Fax:208-524-3950
Practice Address - Street 1:1995 E 17TH ST
Practice Address - Street 2:ST. #4
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6493
Practice Address - Country:US
Practice Address - Phone:208-524-3939
Practice Address - Fax:208-524-3950
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMEDPHYSCOMLIC114155207RG0100X
ID0-122207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
710949800OtherCOMMERCIAL
ID002708700Medicaid
710949800OtherCOMMERCIAL
ID002708700Medicaid