Provider Demographics
NPI:1013015064
Name:WAGGONER, DAVID BO (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BO
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 NW EXPRESSWAY ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3514
Mailing Address - Country:US
Mailing Address - Phone:405-773-1113
Mailing Address - Fax:405-773-1114
Practice Address - Street 1:7000 NW EXPRESSWAY ST
Practice Address - Street 2:SUITE H
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-3514
Practice Address - Country:US
Practice Address - Phone:405-773-1113
Practice Address - Fax:405-773-1114
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3170111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician