Provider Demographics
NPI:1063469419
Name:WAGENKNECHT, WALTER (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:WAGENKNECHT
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:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01302-0910
Mailing Address - Country:US
Mailing Address - Phone:413-772-8500
Mailing Address - Fax:413-772-8900
Practice Address - Street 1:17 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7601
Practice Address - Country:US
Practice Address - Phone:800-655-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT04200100632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1004285Medicaid
VN246201Medicare PIN
VT1004285Medicaid