Provider Demographics
NPI:1649212549
Name:WIGTON, ROGER BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:BRUCE
Last Name:WIGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5216 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1404
Mailing Address - Country:US
Mailing Address - Phone:703-931-4746
Mailing Address - Fax:703-931-1794
Practice Address - Street 1:5216 DAWES AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1404
Practice Address - Country:US
Practice Address - Phone:703-931-4746
Practice Address - Fax:703-931-1794
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029799207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006045201Medicaid
VA078284OtherANTHEM BCBS
VI0004OtherCAREFIRST BSBC
VA078284OtherANTHEM BCBS
VAB93741Medicare UPIN