Basic Information
| Provider Information | |||||||||
| NPI: | 1477618122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIGGINS | ||||||||
| FirstName: | JIBRI | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831000 | ||||||||
| FaxNumber: | 9043831412 | ||||||||
| Practice Location | |||||||||
| Address1: | 15255 MAX LEGGETT PKWY | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322187273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043831000 | ||||||||
| FaxNumber: | 9043831412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2006 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 00025592 | AL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | ME125439 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 015845600 | 05 | FL | MEDICAID |