Provider Demographics
NPI:1275530248
Name:WAGNER, BARBARA R (MD)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:R
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 1:4900 MANATEE AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3859
Mailing Address - Country:US
Mailing Address - Phone:941-746-5200
Mailing Address - Fax:941-746-5266
Practice Address - Street 1:4900 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-3859
Practice Address - Country:US
Practice Address - Phone:941-746-5200
Practice Address - Fax:941-746-5266
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110212152OtherRAILROAD MEDICARE
FL47063OtherBLUE CROSS / BLUE SHIELD
FL110212152OtherRAILROAD MEDICARE
FL47063OtherBLUE CROSS / BLUE SHIELD