1235344011 NPI number — CLINTON WAGGONER MD

Table of content: CLINTON WAGGONER MD (NPI 1235344011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235344011 NPI number — CLINTON WAGGONER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGGONER
Provider First Name:
CLINTON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235344011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32513-9210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-476-8602
Provider Business Mailing Address Fax Number:
850-474-3518

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5151 N 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-8721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-476-8602
Provider Business Practice Location Address Fax Number:
850-474-3518
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  26192 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME111431 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110982 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111222 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51599270 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 007825700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111237 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51599265 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51599269 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 111224 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111236 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 145235 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14P2L . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 51067334 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51599271 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51599266 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51599267 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 592-19398 . This is a "BCBS OF ALABAMA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01133899 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 111238 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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