Provider Demographics
NPI:1316392889
Name:WIGGINS, DIONTE
Entity Type:Individual
Prefix:
First Name:DIONTE
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4653
Mailing Address - Country:US
Mailing Address - Phone:217-258-2581
Mailing Address - Fax:
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4644
Practice Address - Country:US
Practice Address - Phone:217-258-2551
Practice Address - Fax:217-258-2256
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036153297207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine