Provider Demographics
NPI:1679007843
Name:WAGGONER, GARRETT RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:RUSSELL
Last Name:WAGGONER
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 1:21 COLUMBIA ST STE 102
Mailing Address - Street 2:APT 102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1133
Mailing Address - Country:US
Mailing Address - Phone:407-841-5145
Mailing Address - Fax:407-841-5101
Practice Address - Street 1:7526 NE 6TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33138-5101
Practice Address - Country:US
Practice Address - Phone:479-462-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME146059207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine