Provider Demographics
NPI:1689670580
Name:JAGGERNAUTH, WAINWRIGHT ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:WAINWRIGHT
Middle Name:ANTHONY
Last Name:JAGGERNAUTH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4299
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:
Practice Address - Street 1:1200 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1921
Practice Address - Country:US
Practice Address - Phone:419-794-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010939742085R0001X
NY0020012085R0001X
OH35.0930442085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02460520Medicaid
MI1689670580OtherMI MEDICAID-OH LOCATIONS
OH2949920Medicaid
MI1689670580Medicaid
OHP00746491OtherRR MEDICARE
MI0N24000021Medicare PIN
NYH95121Medicare UPIN
OHP00746491OtherRR MEDICARE