Provider Demographics
NPI:1295833796
Name:WAGGONER, BRADLEY SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:SCOTT
Last Name:WAGGONER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:21216 NORTHWEST FWY
Mailing Address - Street 2:SUITE 540
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-4695
Mailing Address - Country:US
Mailing Address - Phone:281-640-8373
Mailing Address - Fax:281-640-8377
Practice Address - Street 1:21216 NORTHWEST FWY
Practice Address - Street 2:SUITE 540
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-4695
Practice Address - Country:US
Practice Address - Phone:281-640-8373
Practice Address - Fax:281-640-8377
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-08-11
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Provider Licenses
StateLicense IDTaxonomies
TXL9953208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3992Medicare PIN