Provider Demographics
NPI:1114015138
Name:WAGNER, HAROLD G (DO)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:G
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7441 MARVIN D LOVE FWY
Mailing Address - Street 2:STE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3490
Mailing Address - Country:US
Mailing Address - Phone:972-572-1998
Mailing Address - Fax:972-572-4842
Practice Address - Street 1:7441 MARVIN D LOVE FWY
Practice Address - Street 2:STE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3490
Practice Address - Country:US
Practice Address - Phone:972-572-1998
Practice Address - Fax:972-572-4842
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6679207P00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00207035OtherRAILROAD MEDICARE PIN
TX008PHOtherBCBS PIN
TX140123437Medicaid
TXE81851Medicare UPIN
TXP00207035OtherRAILROAD MEDICARE PIN