Provider Demographics
NPI:1639185341
Name:WAGGONER, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 E CITIZENS DR STE 6
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4797
Mailing Address - Country:US
Mailing Address - Phone:479-582-1212
Mailing Address - Fax:
Practice Address - Street 1:2630 E CITIZENS DR STE 6
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4797
Practice Address - Country:US
Practice Address - Phone:479-582-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR2411152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127297722Medicaid
AR127297722Medicaid
AR3893570001Medicare NSC
AR48930Medicare PIN