Provider Demographics
NPI:1932490075
Name:WIGGINTON, CHRISTINE ANN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:WIGGINTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ANN
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:221 NE GLEN OAK AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-5582
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636
Practice Address - Country:US
Practice Address - Phone:309-672-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-24
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00777122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology