Healthcare Provider Details

I. General information

NPI: 1437384708
Provider Name (Legal Business Name): JACQUELINE E WUNDERLICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 W. MAIN STREET
SHELBY OH
44875-0000
US

IV. Provider business mailing address

335 GLESSNER AVE
MANSFIELD OH
44903-2269
US

V. Phone/Fax

Practice location:
  • Phone: 419-342-5015
  • Fax:
Mailing address:
  • Phone: 419-526-8000
  • Fax: 419-526-8834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.120343
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: