Healthcare Provider Details

I. General information

NPI: 1043501976
Provider Name (Legal Business Name): JACOB JOHN WINGERTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S MCCASLIN BLVD STE 103
SUPERIOR CO
80027-9701
US

IV. Provider business mailing address

400 S MCCASLIN BLVD STE 103
SUPERIOR CO
80027-9701
US

V. Phone/Fax

Practice location:
  • Phone: 303-666-7337
  • Fax:
Mailing address:
  • Phone: 303-666-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR0053948
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: