Provider Demographics
NPI:1003081357
Name:WAGGONER, JESSE JULIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:JULIAN
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1301 SHOREWAY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-4151
Mailing Address - Country:US
Mailing Address - Phone:650-596-7000
Mailing Address - Fax:650-596-7096
Practice Address - Street 1:1301 SHOREWAY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4151
Practice Address - Country:US
Practice Address - Phone:650-596-7000
Practice Address - Fax:650-596-7096
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA110151207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine