Healthcare Provider Details

I. General information

NPI: 1477535474
Provider Name (Legal Business Name): GREGORY MARK WIGGINS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 ARLINGTON DR
VIDALIA GA
30474-7209
US

IV. Provider business mailing address

205 ARLINGTON DR
VIDALIA GA
30474-7209
US

V. Phone/Fax

Practice location:
  • Phone: 912-537-2559
  • Fax: 912-537-9668
Mailing address:
  • Phone: 912-537-2559
  • Fax: 912-537-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD000802
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: