Provider Demographics
NPI:1043397847
Name:WIGFALL, PRESTON A (MD)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:A
Last Name:WIGFALL
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 1:196 NORTH ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:196 NORTH ST
Practice Address - Street 2:GENEVA GENERAL HOSPITAL
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1651
Practice Address - Country:US
Practice Address - Phone:315-787-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156463207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02642193Medicaid
NY02642193Medicaid