Provider Demographics
NPI:1992021190
Name:MICHAEL WAGGONER OD PA
Entity Type:Organization
Organization Name:MICHAEL WAGGONER OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-582-1212
Mailing Address - Street 1:2630 E CITIZENS DR STE 6
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4797
Mailing Address - Country:US
Mailing Address - Phone:479-582-1212
Mailing Address - Fax:479-582-2070
Practice Address - Street 1:2630 E CITIZENS DR STE 6
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4797
Practice Address - Country:US
Practice Address - Phone:479-582-1212
Practice Address - Fax:479-582-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2411302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1639185341OtherNPI
AR5G500OtherMEDICARE GROUP PTAN
AR127297722Medicaid
AR1992021190OtherGROUP NPI
AR5G500OtherMEDICARE GROUP PTAN
AR1639185341OtherNPI
AR3893570001Medicare NSC