Provider Demographics
NPI:1225034853
Name:WAGONER, GARY L (MD P A)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 BISHOP WALSH RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1845
Mailing Address - Country:US
Mailing Address - Phone:301-777-5326
Mailing Address - Fax:301-777-0325
Practice Address - Street 1:925 BISHOP WALSH RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-777-5326
Practice Address - Fax:301-777-0325
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0022181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189121900Medicaid
MD218706OtherUNITED HEALTH CARE
MDP11723OtherBLUE SHIELD POS
MD8814GLOtherCAREFIRST BS
MDW0230001OtherFEDERAL BS
MD104012109OtherCIGNA
MD408113495OtherR.R. MEDICARE
MD189121900Medicaid
MDW0230001OtherFEDERAL BS