Provider Demographics
NPI:1093743502
Name:WAGNER, BRIAN KEITH (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
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 1:11 SOUTH ROAD
Mailing Address - Street 2:LOWER LEVEL 20
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-470-5703
Mailing Address - Fax:860-606-8025
Practice Address - Street 1:11 SOUTH RD LOWR LEVEL20
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2483
Practice Address - Country:US
Practice Address - Phone:860-470-5703
Practice Address - Fax:860-606-8025
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000793213E00000X, 213ER0200X, 213ES0131X
CT000862213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT480000942Medicare ID - Type Unspecified
CTV00867Medicare UPIN