Provider Demographics
NPI:1558406066
Name:WAGGONER, DANIEL LEROY (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEROY
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 WATERFORD PKWY S STE 305B
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1245
Mailing Address - Country:US
Mailing Address - Phone:860-536-2995
Mailing Address - Fax:860-536-7098
Practice Address - Street 1:196 WATERFORD PKWY S STE 305B
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1245
Practice Address - Country:US
Practice Address - Phone:860-536-2995
Practice Address - Fax:860-536-7098
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2025-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45087207K00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
H76865Medicare UPIN