Provider Demographics
NPI:1164419081
Name:WAGNER, ROBERT J JR (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WAGNER
Suffix:JR
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 1:5801 ALLENTOWN RD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20746-4563
Mailing Address - Country:US
Mailing Address - Phone:240-427-1630
Mailing Address - Fax:240-492-2070
Practice Address - Street 1:5801 ALLENTOWN RD
Practice Address - Street 2:SUITE 502
Practice Address - City:CAMP SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:20746
Practice Address - Country:US
Practice Address - Phone:240-427-1630
Practice Address - Fax:240-492-2070
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0061922207QA0505X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH43765Medicare UPIN