MEDICARE: DR. ROGER BRUCE WIGTON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	0101029799	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	078284	OTHER	VA	ANTHEM BCBS
3	0004	OTHER	VI	CAREFIRST BSBC

General Provider Information

NPI Number	:	1649212549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER BRUCE WIGTON M.D.

Provider Business Mailing Address
First Line	:	5216 DAWES AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22311-1404
Country	:	US
Telephone Number	:	703-931-4746
Fax Number	:	703-931-1794

Provider Business Practice Location Address
First Line	:	5216 DAWES AVE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22311-1404
Country	:	US
Telephone Number	:	703-931-4746
Fax Number	:	703-931-1794

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	11/23/2009

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