Healthcare Provider Details

I. General information

NPI: 1306772587
Provider Name (Legal Business Name): DAVID WAGGONER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S WOOD ST
CHICAGO IL
60612-4325
US

IV. Provider business mailing address

501 E 32ND ST APT 9-0412
CHICAGO IL
60616-4053
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-1790
  • Fax:
Mailing address:
  • Phone: 317-775-5841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number$$$$$$$$$
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: