Provider Demographics
NPI:1003893454
Name:WAGLE, NIKHIL SUDHAKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKHIL
Middle Name:SUDHAKAR
Last Name:WAGLE
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 1:777 TANGLEFOOT LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1650
Mailing Address - Country:US
Mailing Address - Phone:563-323-2020
Mailing Address - Fax:563-328-5694
Practice Address - Street 1:4731 45TH STREET CT
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7102
Practice Address - Country:US
Practice Address - Phone:309-793-2020
Practice Address - Fax:309-793-2602
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33115207W00000X, 207WX0009X
IL036-100181207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0060350OtherIA GROUP MEDICAID
IA26568OtherIA GROUP MEDICARE
IL790730OtherIL GROUP MEDICARE
IA0910546Medicaid
IA26568OtherIA GROUP MEDICARE