Provider Demographics
NPI:1710961347
Name:WIGGINS, GREGORY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHARLES
Last Name:WIGGINS
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 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7500
Mailing Address - Fax:269-341-7540
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M124
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:269-341-7540
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8159207T00000X
MI4301065499207T00000X
WAMD00039713207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C97618OtherBCBSM
MI1710961347Medicaid
CA00A816590Medicaid
MI4843879Medicaid
MI0C97618OtherBCBSM
H43693Medicare UPIN