Provider Demographics
NPI:1265448328
Name:WAGNER, DAVID C (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:C
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLETTE
Practice Address - State:MI
Practice Address - Zip Code:48453-1508
Practice Address - Country:US
Practice Address - Phone:989-635-3660
Practice Address - Fax:989-635-3662
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750095Medicare PIN