=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417915943
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JON G WININGER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 10/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1125 SAINT GEORGES AVE
-----------------------------------------------------
City | RAHWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07065-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-499-0440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1125 SAINT GEORGES AVE
-----------------------------------------------------
City | RAHWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07065-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-499-0440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MA035301
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------