Provider Demographics
NPI:1073576336
Name:WAGNER, RICHARD F (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:F
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 1:4220 WILDERNESS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-4416
Mailing Address - Country:US
Mailing Address - Phone:262-554-0328
Mailing Address - Fax:
Practice Address - Street 1:252 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1828
Practice Address - Country:US
Practice Address - Phone:262-767-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20111207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30773500Medicaid
WI30773500Medicaid
WI000401674Medicare ID - Type Unspecified