Provider Demographics
NPI:1093918021
Name:WAGNER, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
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 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-543-7389
Mailing Address - Fax:410-543-7595
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-543-7389
Practice Address - Fax:410-543-7595
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0009592207ZP0102X
MDD71661207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology