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General NPI Number Information
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NPI Number | 1790966810
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Entity Type | Organization
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Legal Business Name | MARCUS WIGUTOW, M.D., INC.
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Dates
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Enumeration Date | 11/16/2007
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Last Update Date | 11/19/2007
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Provider Practice Location Address
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Address Line | 9120 CONNECTICUT DR SUITE E
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City | MERRILLVILLE
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State | IN
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Zip | 46410-7172
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Country | US
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Telephone | 219-769-5900
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Fax | 219-769-5987
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Provider Business Mailing Address
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Address Line | 9120 CONNECTICUT DR. SUITE E
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City | MERRILLVILLE
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State | IN
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Zip | 46410-7172
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Country | US
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Telephone | 219-759-5900
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Fax | 219-769-5987
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARCUS WIGUTOW
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Credential | M.D.
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Telephone | 219-769-5900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 01022387B
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License Number State | IN
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