Active NPI
Brian Leo Waggoner, M.D.
- Pediatrics Physician
- Clive, IA
National Provider Identifier
1679544548
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 28129
- Practice address
- 2555 Berkshire Pkwy Ste a
Clive, IA 50325-4646 - Phone
- (515) 987-0051
- Fax
- (515) 987-0054
- NPI assigned
- Jan 30, 2006
- Last updated
- Dec 23, 2016
- 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 |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 28129 | IA | Primary |
Addresses
Primary practice location
2555 Berkshire Pkwy Ste a
Clive, IA 50325-4646
Mailing address
2555 Berkshire Pkwy Ste a
Clive, IA 50325-4646
Phone (515) 987-0051
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0071670 | Medicaid | IA | |
| 03583 | Other | IA | BCBS |
| 47500 | Other | IA | BCBS |
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)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 28129 | IA | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Waggoner Pediatrics, PLC | Pediatrics | 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 Waggoner Pediatrics of Central Iowa
- Pediatrics Physician
- Clive, IA
- NPI 1225572548
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1138579200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1482451200000",
"number": "1679544548",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2555 BERKSHIRE PKWY STE A",
"city": "CLIVE",
"state": "IA",
"postal_code": "503254646",
"telephone_number": "515-987-0051",
"fax_number": "515-987-0054"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2555 BERKSHIRE PKWY STE A",
"city": "CLIVE",
"state": "IA",
"postal_code": "503254646",
"telephone_number": "515-987-0051",
"fax_number": "515-987-0054"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGGONER",
"first_name": "BRIAN",
"middle_name": "LEO",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-01-30",
"last_updated": "2016-12-23",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "IA",
"license": "28129",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0071670",
"state": "IA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "03583",
"state": "IA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "47500",
"state": "IA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Clive, IA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.