Provider Demographics
NPI:1750350948
Name:WAGGONER, SAMINA M (MD)
Entity type:Individual
Prefix:
First Name:SAMINA
Middle Name:M
Last Name:WAGGONER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SAMINA
Other - Middle Name:T
Other - Last Name:MAJID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:718 GLENVIEW AVENUE
Mailing Address - Street 2:HIGHLAND PARK HOSPITAL
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035
Mailing Address - Country:US
Mailing Address - Phone:847-480-2833
Mailing Address - Fax:847-480-2675
Practice Address - Street 1:718 GLENVIEW AVE
Practice Address - Street 2:HIGHLAND PARK HOSPITAL
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-480-2833
Practice Address - Fax:847-480-2675
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112866208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL021622158OtherGROUP BLUE SHIELD NUMBER
IL036112866Medicaid
I39913Medicare UPIN
ILK23311Medicare PIN
IL036112866Medicaid