Provider Demographics
NPI:1942307343
Name:WIGGINTON, LARRY S (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:S
Last Name:WIGGINTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2211 MAYFAIR DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-4569
Mailing Address - Country:US
Mailing Address - Phone:270-926-8222
Mailing Address - Fax:270-685-5101
Practice Address - Street 1:2211 MAYFAIR DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4569
Practice Address - Country:US
Practice Address - Phone:270-926-8222
Practice Address - Fax:270-685-5101
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY14856207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64148562Medicaid
KY64148562Medicaid
C71173Medicare UPIN