Provider Demographics
NPI:1053874776
Name:UNTERINER, JACKSON GEORGE (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:GEORGE
Last Name:UNTERINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE, CB 8131
Mailing Address - Street 2:CB 8131
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-362-5000
Mailing Address - Fax:
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-447-8786
Practice Address - Fax:502-447-8786
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200117362085R0202X
KY604482085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300110382Medicaid
KY7101050170Medicaid