Provider Demographics
NPI:1063674299
Name:WAGNER, TODD EMMIT (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:EMMIT
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 1:21100 SOUTHGATE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3004
Mailing Address - Country:US
Mailing Address - Phone:216-663-6100
Mailing Address - Fax:216-395-1071
Practice Address - Street 1:21100 SOUTHGATE PARK BLVD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3004
Practice Address - Country:US
Practice Address - Phone:216-663-6100
Practice Address - Fax:216-395-1071
Is Sole Proprietor?:No
Enumeration Date:2008-06-29
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.099746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine