MEDICARE: ERIC A WINGERSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	MEDPHYSCOMLIC114155	MT
2	207RG0100X	Gastroenterology Physician	0-122	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	710949800	OTHER		COMMERCIAL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295738797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC A WINGERSON D.O.

Provider Business Mailing Address
First Line	:	1995 E 17TH ST
Second Line	:	ST. #4
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6493
Country	:	US
Telephone Number	:	208-524-3939
Fax Number	:	208-524-3950

Provider Business Practice Location Address
First Line	:	1995 E 17TH ST
Second Line	:	ST. #4
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6493
Country	:	US
Telephone Number	:	208-524-3939
Fax Number	:	208-524-3950

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	01/02/2024

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Directions to “ ERIC A WINGERSON D.O.” Practice Location

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