Provider Demographics
NPI:1588835383
Name:ROD WIGLE M.D., LLC
Entity Type:Organization
Organization Name:ROD WIGLE M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-388-4138
Mailing Address - Street 1:1693 SW CHANDLER AVE
Mailing Address - Street 2:250
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3236
Mailing Address - Country:US
Mailing Address - Phone:541-388-0673
Mailing Address - Fax:541-388-2619
Practice Address - Street 1:1693 SW CHANDLER AVE
Practice Address - Street 2:250
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3236
Practice Address - Country:US
Practice Address - Phone:541-388-0673
Practice Address - Fax:541-388-2619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13088207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277913Medicaid
ORR11875Medicare PIN