Provider Demographics
NPI:1114198751
Name:WAGNER, MATTHEW ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 112 BLDG 2C
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8055
Mailing Address - Country:US
Mailing Address - Phone:631-371-8034
Mailing Address - Fax:631-828-7899
Practice Address - Street 1:1500 ROUTE 112 BLDG 2C
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-8055
Practice Address - Country:US
Practice Address - Phone:631-371-8034
Practice Address - Fax:631-828-7899
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103612207XP3100X
NY251727207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY120130521000407OtherMEDICARE