Provider Demographics
NPI:1679556609
Name:WIGNESWARAN, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:WIGNESWARAN
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 1:1 ELIZABETH PL
Mailing Address - Street 2:SUITE 190
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45408-1445
Mailing Address - Country:US
Mailing Address - Phone:937-222-3118
Mailing Address - Fax:937-222-1436
Practice Address - Street 1:455 TURNER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3630
Practice Address - Country:US
Practice Address - Phone:937-208-7930
Practice Address - Fax:937-222-7910
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH080805207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
310821503033OtherMEDICARE RAILROAD
000000221825OtherANTHEM
2809872OtherAETNA
3120003OtherUHC
3108215037021OtherUNITED MINE WORKERS
OH2306918Medicaid
D80805OtherHUMANA
2809872OtherAETNA
OH4070711Medicare ID - Type Unspecified