Provider Demographics
NPI: | 1669584603 |
---|---|
Name: | WIGGANS, JOHN C (MD) |
Entity type: | Individual |
Prefix: | DR |
First Name: | JOHN |
Middle Name: | C |
Last Name: | WIGGANS |
Suffix: | |
Gender: | M |
Credentials: | MD |
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 843225 |
Mailing Address - Street 2: | |
Mailing Address - City: | KANSAS CITY |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 64184-3225 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 708-633-1234 |
Mailing Address - Fax: | 708-342-7100 |
Practice Address - Street 1: | 3250 GORDONVILLE RD |
Practice Address - Street 2: | SUITE 358 |
Practice Address - City: | CAPE GIRARDEAU |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63703-5056 |
Practice Address - Country: | US |
Practice Address - Phone: | 573-331-3155 |
Practice Address - Fax: | 573-331-5096 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-31 |
Last Update Date: | 2010-02-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 2001001485 | 208G00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 1669584603 | Medicaid | |
MO | P00772953 | Other | RR MCR |
MO | 454668 | Other | HEALTHLINK |
MO | 205382807 | Medicaid | |
MO | 604417 | Other | BCBS |
MO | 205382807 | Medicaid |