Provider Demographics
NPI:1114085578
Name:WAGNER, KAREN D (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:RT 1022
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-1022
Mailing Address - Country:US
Mailing Address - Phone:409-772-0848
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:RT 1022
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1022
Practice Address - Country:US
Practice Address - Phone:409-772-0848
Practice Address - Fax:409-772-0885
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH72472084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125044102Medicaid
TX125044102Medicaid
TX82678NMedicare ID - Type Unspecified