Basic Information
| Provider Information | |||||||||
| NPI: | 1902877244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WURSTER | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7245 E OSBORN RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852516443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809945012 | ||||||||
| FaxNumber: | 4809907364 | ||||||||
| Practice Location | |||||||||
| Address1: | 7245 E OSBORN RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852516443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809945012 | ||||||||
| FaxNumber: | 4809907364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 12/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 30930 | AZ | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 818065 | 05 | AZ | MEDICAID |