Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | ME32546 | FL |
NPI | 1013919158 |
---|---|
Provider Name | Joseph Theodore Wingard |
First Address | Jacksonville, FL 32204-4735 |
Second Address | Jacksonville, FL 32204-4735 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2005 |
Last Update Date | 07/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D52593 | (02) | FL |