Provider Demographics
NPI:1255331914
Name:WAGGONER, BRIAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:S
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 1:428 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2339
Mailing Address - Country:US
Mailing Address - Phone:931-854-9988
Mailing Address - Fax:931-854-9977
Practice Address - Street 1:428 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2339
Practice Address - Country:US
Practice Address - Phone:931-854-9988
Practice Address - Fax:931-854-9977
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD27530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4033875OtherBLUE CROSS BLUE SHIELD
TN3812970Medicaid
TN4033875OtherBLUE CROSS BLUE SHIELD
3812970Medicare ID - Type Unspecified