Provider Demographics
NPI:1962560409
Name:WIGGINS, HENRY W (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:W
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9410 COMPUBILL DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462
Mailing Address - Country:US
Mailing Address - Phone:708-460-7444
Mailing Address - Fax:708-460-8662
Practice Address - Street 1:326 WEST 64TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621
Practice Address - Country:US
Practice Address - Phone:773-962-3900
Practice Address - Fax:773-962-4399
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360393802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039380Medicaid
D12257Medicare UPIN
IL325500Medicare ID - Type Unspecified