Provider Demographics
NPI:1740243450
Name:WIGGINTON, JANE GRAYSON (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:GRAYSON
Last Name:WIGGINTON
Suffix:
Gender:F
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-648-3067
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-648-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5743207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117131602Medicaid
TX117131602Medicaid
TX8150J5Medicare ID - Type Unspecified