Provider Demographics
NPI:1033262340
Name:WAGNER, JOHN D (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD, MBA
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Mailing Address - Street 1:451 CLARKSON AVE RM B-1147
Mailing Address - Street 2:KINGS COUNTY HOSPITAL CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2054
Mailing Address - Country:US
Mailing Address - Phone:718-245-3921
Mailing Address - Fax:718-245-5347
Practice Address - Street 1:451 CLARKSON AVE RM B-1147
Practice Address - Street 2:KINGS COUNTY HOSPITAL CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-3921
Practice Address - Fax:718-245-5347
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2014-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY140277207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00837072Medicaid
C06536Medicare UPIN
NY00837072Medicaid