Active NPI
Carl Waggoner, MD
- Family Medicine Physician
- Newark, OH
National Provider Identifier
1043218068
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 35-043176
- Practice address
- 1272 W Main St
BLDG. 5
Newark, OH 43055-2034 - Phone
- (740) 348-1788
- Fax
- (740) 348-1789
- NPI assigned
- Jul 13, 2005
- Last updated
- Jun 21, 2010
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 35-043176 | OH | Primary |
Addresses
Primary practice location
1272 W Main St
BLDG. 5
Newark, OH 43055-2034
Mailing address
1272 W Main St
BLDG. 5
Newark, OH 43055-2034
Phone (740) 348-1788
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 416615 | Medicaid | OH | |
| 0101480 | Other | OH | UHC |
| 4400430 | Other | OH | AETNA |
| 1822763 | Other | OH | FIRST HEALTH |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 35-043176 | OH | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Licking Memorial Professional Corp. | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Licking Memorial Pediatrics-Utica
- Pediatrics Physician
- Utica, OH
- NPI 1497771521
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1121212800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1277078400000",
"number": "1043218068",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1272 W MAIN ST",
"address_2": "BLDG. 5",
"city": "NEWARK",
"state": "OH",
"postal_code": "430552034",
"telephone_number": "740-348-1788",
"fax_number": "740-348-1789"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1272 W MAIN ST",
"address_2": "BLDG. 5",
"city": "NEWARK",
"state": "OH",
"postal_code": "430552034",
"telephone_number": "740-348-1788",
"fax_number": "740-348-1789"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGGONER",
"first_name": "CARL",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-07-13",
"last_updated": "2010-06-21",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "OH",
"license": "35-043176",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "416615",
"state": "OH"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UHC",
"identifier": "0101480",
"state": "OH"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA",
"identifier": "4400430",
"state": "OH"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FIRST HEALTH",
"identifier": "1822763",
"state": "OH"
}
],
"endpoints": [],
"other_names": []
}Other providers in Newark, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.