Provider Demographics
NPI:1679624597
Name:WAGGONER, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
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 1:411 WALNUT ST
Mailing Address - Street 2:SUITE 8615
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-3443
Mailing Address - Country:US
Mailing Address - Phone:615-297-7390
Mailing Address - Fax:
Practice Address - Street 1:201 W AVALON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2805
Practice Address - Country:US
Practice Address - Phone:256-386-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY279972084P0800X
AL137832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC-75925Medicare UPIN