Provider Demographics
NPI:1073664132
Name:WAGNER, ABRAHAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 WASHINGTON ST STE 403
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8249
Mailing Address - Country:US
Mailing Address - Phone:954-922-7333
Mailing Address - Fax:954-248-6925
Practice Address - Street 1:3700 WASHINGTON ST STE 403
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8249
Practice Address - Country:US
Practice Address - Phone:954-922-7333
Practice Address - Fax:954-248-6925
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 3262213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD412XMedicare Oscar/Certification