=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366651614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS WIGGINTON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 04/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 169 RIVERSIDE DR
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13905-4246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-321-8466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 169 RIVERSIDE DR
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13905-4246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-321-8466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 266252
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------