Healthcare Provider Details

I. General information

NPI: 1679544548
Provider Name (Legal Business Name): BRIAN LEO WAGGONER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 BERKSHIRE PKWY STE A
CLIVE IA
50325-4646
US

IV. Provider business mailing address

2555 BERKSHIRE PKWY STE A
CLIVE IA
50325-4646
US

V. Phone/Fax

Practice location:
  • Phone: 515-987-0051
  • Fax: 515-987-0054
Mailing address:
  • Phone: 515-987-0051
  • Fax: 515-987-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28129
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier47500
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBCBS
# 2
Identifier03583
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerBCBS
# 3
Identifier0071670
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: