Provider Demographics
NPI:1891083812
Name:WAGGONER, THOMAS E I (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:WAGGONER
Suffix:I
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 1:3375 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2306
Mailing Address - Country:US
Mailing Address - Phone:520-838-2148
Mailing Address - Fax:
Practice Address - Street 1:2404 E RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6521
Practice Address - Country:US
Practice Address - Phone:520-838-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11212207RC0000X
NJ25MB09443300207RC0000X
AZ006643207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease