1679556609 NPI number — JOHN R WIGNESWARAN MD

Table of content: JOHN R WIGNESWARAN MD (NPI 1679556609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679556609 NPI number — JOHN R WIGNESWARAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIGNESWARAN
Provider First Name:
JOHN
Provider Middle Name:
R
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:
1679556609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ELIZABETH PL
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45408-1445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-222-3118
Provider Business Mailing Address Fax Number:
937-222-1436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 TURNER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45415-3630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-208-7930
Provider Business Practice Location Address Fax Number:
937-222-7910
Provider Enumeration Date:
11/23/2005

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: 207RN0300X , with the licence number:  080805 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 310821503033 . This is a "MEDICARE RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000221825 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2809872 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3120003 . This is a "UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3108215037021 . This is a "UNITED MINE WORKERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2306918 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: D80805 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".




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