Provider Demographics
NPI:1033321914
Name:WAGNER, JEFFREY C (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:C
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 1:499 E HAMPDEN AVE STE 360
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3877
Mailing Address - Country:US
Mailing Address - Phone:303-781-4485
Mailing Address - Fax:
Practice Address - Street 1:499 E HAMPDEN AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2780
Practice Address - Country:US
Practice Address - Phone:303-781-4485
Practice Address - Fax:303-788-7666
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE267442084N0400X
UT6312366-12052084N0400X
CO481152084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA105215OtherMEMORIAL HOSPITAL UPIN