Provider Demographics
NPI:1235344011
Name:WAGGONER, CLINTON (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
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:PO BOX 9210
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-9210
Mailing Address - Country:US
Mailing Address - Phone:850-476-8602
Mailing Address - Fax:850-474-3518
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-476-8602
Practice Address - Fax:850-474-3518
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261922085R0202X
FLME1114312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL110982Medicaid
AL111222Medicaid
AL51599270OtherBCBS
FL007825700Medicaid
AL111237Medicaid
AL51599265OtherBCBS
AL51599269OtherBCBS
AL111224Medicaid
AL111236Medicaid
AL145235Medicaid
FL14P2LOtherBCBS OF FLORIDA
AL51067334OtherBCBS
AL51599271OtherBCBS
AL51599266OtherBCBS
AL51599267OtherBCBS
FL592-19398OtherBCBS OF ALABAMA
FLP01133899OtherRAILROAD MEDICARE
AL111238Medicaid
AL51599265OtherBCBS
AL111237Medicaid
AL111224Medicaid