Healthcare Provider Details

I. General information

NPI: 1083840524
Provider Name (Legal Business Name): JACOB WYNES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 KERNAN DRIVE
BALTIMORE MD
21207
US

IV. Provider business mailing address

2200 KERNAN DRIVE
BALTIMORE MD
21207
US

V. Phone/Fax

Practice location:
  • Phone: 410-448-7112
  • Fax:
Mailing address:
  • Phone: 410-448-7112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberO1555
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: