Provider Demographics
NPI:1780646166
Name:WIGDOR, CLIFFORD ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:ROBERT
Last Name:WIGDOR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 NUTLEY PLACE
Mailing Address - Street 2:
Mailing Address - City:NORTH WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:516-791-6234
Mailing Address - Fax:
Practice Address - Street 1:1344 50TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219
Practice Address - Country:US
Practice Address - Phone:718-436-2036
Practice Address - Fax:718-871-2013
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002395213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T50753Medicare UPIN
NY00413387Medicare ID - Type Unspecified
P289813Medicare ID - Type Unspecified