Provider Demographics
NPI:1043218068
Name:WAGGONER, CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:WAGGONER
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 1:1272 W MAIN ST
Mailing Address - Street 2:BLDG. 5
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2034
Mailing Address - Country:US
Mailing Address - Phone:740-348-1788
Mailing Address - Fax:740-348-1789
Practice Address - Street 1:1272 W MAIN ST
Practice Address - Street 2:BLDG. 5
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2034
Practice Address - Country:US
Practice Address - Phone:740-348-1788
Practice Address - Fax:740-348-1789
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-043176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0101480OtherUHC
OH1822763OtherFIRST HEALTH
OH416615Medicaid
OH4400430OtherAETNA
OH0537065Medicare ID - Type Unspecified
OHCO2598Medicare UPIN