Provider Demographics
NPI:1295963999
Name:WAGGONER, MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WAGGONER
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 1:3318 N NORTHHILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4008
Mailing Address - Country:US
Mailing Address - Phone:479-521-2555
Mailing Address - Fax:
Practice Address - Street 1:3737 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-1839
Practice Address - Country:US
Practice Address - Phone:479-246-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5341207W00000X
ARE-8612207W00000X, 207WX0120X
MOT2009017030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200493810AMedicaid
OK298921YRYSMedicare PIN