Provider Demographics
NPI:1023009461
Name:WAGNER, STEPHEN IRWIN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:IRWIN
Last Name:WAGNER
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 1:505 OAKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5700
Mailing Address - Country:US
Mailing Address - Phone:813-654-2273
Mailing Address - Fax:813-654-1384
Practice Address - Street 1:401 OAKFIELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5710
Practice Address - Country:US
Practice Address - Phone:813-654-2273
Practice Address - Fax:813-654-1384
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15542207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057050800Medicaid
FL50720XMedicare PIN
FL057050800Medicaid