Healthcare Provider Details

I. General information

NPI: 1013086651
Provider Name (Legal Business Name): LINDA A. WAGGONER FOUNTAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 W MAIN ST
CHARLOTTESVILLE VA
22903-2824
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-0123
  • Fax: 434-243-3300
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101048721
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number0101048721
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: