Provider Demographics
NPI:1003805367
Name:WIGNALL, WILLIAM B (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:WIGNALL
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 1:1247 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3786
Mailing Address - Country:US
Mailing Address - Phone:541-318-4249
Mailing Address - Fax:
Practice Address - Street 1:1247 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3786
Practice Address - Country:US
Practice Address - Phone:541-318-4249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028100Medicaid
CO01195239Medicaid
E36227Medicare UPIN
OR028100Medicaid
134728Medicare PIN