Provider Demographics
NPI:1376579730
Name:LIGON, DOUGLAS WISTER (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:WISTER
Last Name:LIGON
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 268
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-0268
Mailing Address - Country:US
Mailing Address - Phone:931-289-2929
Mailing Address - Fax:931-289-2930
Practice Address - Street 1:4895 EAST MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061
Practice Address - Country:US
Practice Address - Phone:931-289-2929
Practice Address - Fax:931-289-2930
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD6383207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN810676663OtherTAX IDENTIFACTION
TNMD0000006383OtherMEDICAL LICENSE NUMBER
TNP00282547OtherRAILROAD MEDICARE
TN3148023Medicaid
TN4113788OtherBCBS/TENNCARE SELECT
TN3148023Medicaid
TN810676663OtherTAX IDENTIFACTION