Provider Demographics
NPI:1386819662
Name:WIGHTMAN, CHRISTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:10869 RTE 36 SOUTH
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-0601
Mailing Address - Country:US
Mailing Address - Phone:585-335-3416
Mailing Address - Fax:585-335-8695
Practice Address - Street 1:61 STATE STREET
Practice Address - Street 2:
Practice Address - City:NUNDA
Practice Address - State:NY
Practice Address - Zip Code:14517-9785
Practice Address - Country:US
Practice Address - Phone:585-468-2528
Practice Address - Fax:585-468-5424
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03348941Medicaid
NYJ100000262OtherMEDICARE PTAN