Healthcare Provider Details

I. General information

NPI: 1073957072
Provider Name (Legal Business Name): KELLY ELIZABETH WINGERTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2013
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-4333
  • Fax: 541-388-3446
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number26775
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101275630
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: