Provider Demographics
NPI:1053419564
Name:BRADLEY WAGGONER MD PA
Entity type:Organization
Organization Name:BRADLEY WAGGONER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-955-8884
Mailing Address - Street 1:21216 NORTHWEST FWY
Mailing Address - Street 2:SUITE 540
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-4695
Mailing Address - Country:US
Mailing Address - Phone:281-640-8373
Mailing Address - Fax:281-640-8377
Practice Address - Street 1:21216 NORTHWEST FWY
Practice Address - Street 2:SUITE 540
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-4695
Practice Address - Country:US
Practice Address - Phone:281-640-8373
Practice Address - Fax:281-640-8377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X061Medicare PIN