Healthcare Provider Details

I. General information

NPI: 1295963999
Provider Name (Legal Business Name): MICHAEL WAGGONER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 W WALNUT ST
ROGERS AR
72756-1839
US

IV. Provider business mailing address

3318 N NORTHHILLS BLVD
FAYETTEVILLE AR
72703-4008
US

V. Phone/Fax

Practice location:
  • Phone: 479-246-1700
  • Fax:
Mailing address:
  • Phone: 479-521-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number5341
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberE-8612
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberE-8612
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT2009017030
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: