Healthcare Provider Details

I. General information

NPI: 1376579730
Provider Name (Legal Business Name): DOUGLAS WISTER LIGON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4895 EAST MAIN ST STE A
ERIN TN
37061
US

IV. Provider business mailing address

PO BOX 268
ERIN TN
37061-0268
US

V. Phone/Fax

Practice location:
  • Phone: 931-289-2929
  • Fax: 931-289-2930
Mailing address:
  • Phone: 931-289-2929
  • Fax: 931-289-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD6383
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: