Provider Demographics
NPI:1700174828
Name:WIGGINS, LEWIS MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:LEWIS
Middle Name:MARK
Last Name:WIGGINS
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 1:19TH MEDICAL GROUP
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72099-0001
Mailing Address - Country:US
Mailing Address - Phone:501-987-7319
Mailing Address - Fax:501-987-1464
Practice Address - Street 1:19TH MEDICAL GROUP
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72099-0001
Practice Address - Country:US
Practice Address - Phone:501-987-7319
Practice Address - Fax:501-987-1464
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine