Healthcare Provider Details

I. General information

NPI: 1710988498
Provider Name (Legal Business Name): THOMAS WIGBOLDY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 TATE SPRINGS RD
LYNCHBURG VA
24501-1109
US

IV. Provider business mailing address

1901 TATE SPRINGS RD
LYNCHBURG VA
24501-1109
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-3101
  • Fax:
Mailing address:
  • Phone: 434-200-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102203695
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: