Healthcare Provider Details

I. General information

NPI: 1417983230
Provider Name (Legal Business Name): JONATHAN J WIGGENHORN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N 140TH AVENUE STE 107
GOODYEAR AZ
85395
US

IV. Provider business mailing address

2700 N 140TH AVE STE 107
GOODYEAR AZ
85395-2439
US

V. Phone/Fax

Practice location:
  • Phone: 623-353-8770
  • Fax: 623-353-8771
Mailing address:
  • Phone: 623-537-7085
  • Fax: 623-535-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number4738
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: