Provider Demographics
NPI:1407151632
Name:WIGGINS, ALICIA MICHELLE (MD)
Entity Type:Individual
Prefix:MISS
First Name:ALICIA
Middle Name:MICHELLE
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4408 LOCUST POINT DR
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10465-4038
Mailing Address - Country:US
Mailing Address - Phone:716-857-0553
Mailing Address - Fax:585-626-6061
Practice Address - Street 1:1285 FULTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3401
Practice Address - Country:US
Practice Address - Phone:716-857-0553
Practice Address - Fax:585-626-6061
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071585A207Q00000X
NY2663701207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine