Healthcare Provider Details

I. General information

NPI: 1679556609
Provider Name (Legal Business Name): JOHN R WIGNESWARAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TURNER RD
DAYTON OH
45415-3630
US

IV. Provider business mailing address

1 ELIZABETH PL SUITE 190
DAYTON OH
45408-1445
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-7930
  • Fax: 937-222-7910
Mailing address:
  • Phone: 937-222-3118
  • Fax: 937-222-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number080805
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: