Provider Demographics
NPI:1801858311
Name:WAGGENER, JAMES L (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:L
Last Name:WAGGENER
Suffix:
Gender:M
Credentials:DO
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 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-884-3380
Mailing Address - Fax:817-884-3057
Practice Address - Street 1:855 MONTGOMERY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-884-3380
Practice Address - Fax:817-884-3057
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6341207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BD628OtherBCBS
TX138378813Medicaid
TX8U1313OtherBCBS
TX138378813Medicaid
TX8U1313OtherBCBS