Healthcare Provider Details

I. General information

NPI: 1992021190
Provider Name (Legal Business Name): MICHAEL WAGGONER OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 E CITIZENS DR STE 6
FAYETTEVILLE AR
72703-4797
US

IV. Provider business mailing address

2630 E CITIZENS DR STE 6
FAYETTEVILLE AR
72703-4797
US

V. Phone/Fax

Practice location:
  • Phone: 479-582-1212
  • Fax: 479-582-2070
Mailing address:
  • Phone: 479-582-1212
  • Fax: 479-582-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2411
License Number StateAR

VIII. Authorized Official

Name: MICHAEL WAGGONER
Title or Position: OWNER
Credential:
Phone: 479-582-1212