Provider Demographics
NPI:1679751770
Name:MARK D. WIGOD, MD, PA
Entity Type:Organization
Organization Name:MARK D. WIGOD, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WIGOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-377-9515
Mailing Address - Street 1:3630 E LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7975
Mailing Address - Country:US
Mailing Address - Phone:208-377-9515
Mailing Address - Fax:
Practice Address - Street 1:3630 E LOUISE DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7975
Practice Address - Country:US
Practice Address - Phone:208-377-9515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM81892086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H44448Medicare UPIN
ID1374083Medicare PIN