Organization
MICHAEL WAGGONER OD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL WAGGONER (OWNER)
(479) 582-1212
Entity
Organization
Contact information
Practice address
2630 E CITIZENS DR STE 6, FAYETTEVILLE, AR 72703-4797
(479) 582-1212
(479) 582-2070
Mailing address
2630 E CITIZENS DR STE 6, FAYETTEVILLE, AR 72703-4797
(479) 582-1212
(479) 582-2070
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
2411
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
127297722
—
AR
01
—
1639185341
NPI
AR
01
—
1992021190
GROUP NPI
AR
01
—
5G500
MEDICARE GROUP PTAN
AR
Enumeration date
04/13/2010
Last updated
08/12/2015
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