Provider Demographics
NPI:1730208646
Name:WIBSKOV, JORGEN C (HIS)
Entity type:Individual
Prefix:MR
First Name:JORGEN
Middle Name:C
Last Name:WIBSKOV
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 POTOSI ST STE A
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-2436
Mailing Address - Country:US
Mailing Address - Phone:573-756-1919
Mailing Address - Fax:573-756-9089
Practice Address - Street 1:310 POTOSI ST STE A
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2436
Practice Address - Country:US
Practice Address - Phone:573-756-1919
Practice Address - Fax:573-756-9089
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist