Provider Demographics
NPI:1104847664
Name:WAGGY, NORMAN S (MD)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:S
Last Name:WAGGY
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:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-0459
Mailing Address - Country:US
Mailing Address - Phone:574-825-2146
Mailing Address - Fax:574-825-2182
Practice Address - Street 1:206 W. WARREN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-0459
Practice Address - Country:US
Practice Address - Phone:574-825-2146
Practice Address - Fax:574-825-2182
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030282A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100361050AMedicaid
IN100361050BMedicaid
IN080025301OtherR/R MEDICARE
IN223490DMedicare ID - Type UnspecifiedMILLERSBURG SITE
IND94728Medicare UPIN
IN100361050AMedicaid