Provider Demographics
NPI:1851317846
Name:JORGENSON, WYMAN A (OD)
Entity type:Individual
Prefix:DR
First Name:WYMAN
Middle Name:A
Last Name:JORGENSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 11TH ST N
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4101
Mailing Address - Country:US
Mailing Address - Phone:701-642-4090
Mailing Address - Fax:701-642-9424
Practice Address - Street 1:315 11TH ST N
Practice Address - Street 2:SUITE A
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4101
Practice Address - Country:US
Practice Address - Phone:701-642-4090
Practice Address - Fax:701-642-9424
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND0336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN84M91JOOtherBCBS MN
NDP00215724OtherRAILROAD MEDICARE
ND60152Medicaid
ND25387OtherBCBS ND
ND624891045681OtherPREFERRED ONE
MN2203146OtherMEDICA
MN364223200Medicaid
NDP00215724OtherRAILROAD MEDICARE
ND60152Medicaid
ND25387OtherBCBS ND