Provider Demographics
NPI:1417983230
Name:WIGGENHORN, JONATHAN J (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:J
Last Name:WIGGENHORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 N 140TH AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2439
Mailing Address - Country:US
Mailing Address - Phone:623-537-7085
Mailing Address - Fax:623-535-8771
Practice Address - Street 1:2700 N 140TH AVENUE
Practice Address - Street 2:STE 107
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-353-8770
Practice Address - Fax:623-353-8771
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4738207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ272504Medicaid
AZ272504Medicaid
AZI54820Medicare UPIN