Provider Demographics
NPI:1619060290
Name:WIGAND, AMY C (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:WIGAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1855
Mailing Address - Country:US
Mailing Address - Phone:812-481-2240
Mailing Address - Fax:812-481-2241
Practice Address - Street 1:800 W 9TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2514
Practice Address - Country:US
Practice Address - Phone:812-482-0524
Practice Address - Fax:812-482-0549
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY402482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0276174Medicare ID - Type Unspecified
KYI71463Medicare UPIN