Healthcare Provider Details

I. General information

NPI: 1841465556
Provider Name (Legal Business Name): DONNELL WIGFALL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 12/30/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

IV. Provider business mailing address

1233 HARVARD AVE
CLAREMONT CA
91711-3819
US

V. Phone/Fax

Practice location:
  • Phone: 760-995-8300
  • Fax: 760-955-2356
Mailing address:
  • Phone: 909-762-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20A11625
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: