Provider Demographics
NPI:1477535474
Name:WIGGINS, GREGORY MARK (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MARK
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-7209
Mailing Address - Country:US
Mailing Address - Phone:912-537-2559
Mailing Address - Fax:912-537-9668
Practice Address - Street 1:205 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7209
Practice Address - Country:US
Practice Address - Phone:912-537-2559
Practice Address - Fax:912-537-9668
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000802213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1254360001OtherDMERC
1477535474OtherBLUE CROSS
GA00725018AMedicaid
48SCBSNMedicare PIN
1477535474OtherBLUE CROSS
1254360001Medicare NSC