Provider Demographics
NPI:1033171178
Name:WAGH, ANJU (MD)
Entity Type:Individual
Prefix:DR
First Name:ANJU
Middle Name:
Last Name:WAGH
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 1:285 MIDVALE ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4936
Mailing Address - Country:US
Mailing Address - Phone:201-251-2363
Mailing Address - Fax:201-251-2363
Practice Address - Street 1:3959 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:221-304-7250
Practice Address - Fax:212-544-1974
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2105852080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01860186Medicaid
NY01860186Medicaid
NY549891Medicare ID - Type Unspecified