Provider Demographics
NPI:1881697795
Name:WINTEREGG, MARK R (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:WINTEREGG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10315 DAWSONS CREEK BLVD
Mailing Address - Street 2:STE I
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1912
Mailing Address - Country:US
Mailing Address - Phone:260-490-3400
Mailing Address - Fax:260-489-5930
Practice Address - Street 1:10315 DAWSONS CREEK BLVD
Practice Address - Street 2:STE I
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1912
Practice Address - Country:US
Practice Address - Phone:260-490-3400
Practice Address - Fax:260-489-5930
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-11-27
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
IN08001604A111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092552OtherBLUE CROSS/BLUE SHIELD
IN925290Medicare PIN
INU58728Medicare UPIN