Healthcare Provider Details

I. General information

NPI: 1013015064
Provider Name (Legal Business Name): DAVID BO WAGGONER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 NW EXPRESSWAY ST SUITE H
OKLAHOMA CITY OK
73132-3514
US

IV. Provider business mailing address

7000 NW EXPRESSWAY ST SUITE H
OKLAHOMA CITY OK
73132-3514
US

V. Phone/Fax

Practice location:
  • Phone: 405-773-1113
  • Fax: 405-773-1114
Mailing address:
  • Phone: 405-773-1113
  • Fax: 405-773-1114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3170
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: