Provider Demographics
NPI:1033202502
Name:WAGNER, MARK ELLIOT (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIOT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19601-2201
Mailing Address - Country:US
Mailing Address - Phone:610-374-8585
Mailing Address - Fax:610-374-2574
Practice Address - Street 1:623 NORTH 5TH STREET
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19601
Practice Address - Country:US
Practice Address - Phone:610-374-8585
Practice Address - Fax:610-374-2574
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005358-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0966530Medicaid
PA0966530Medicaid
PAE02523Medicare UPIN