Provider Demographics
NPI:1275571093
Name:WAGMAN, DAVID LOUIS (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LOUIS
Last Name:WAGMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:125 FAIR MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19518-1146
Mailing Address - Country:US
Mailing Address - Phone:215-651-8180
Mailing Address - Fax:215-933-3120
Practice Address - Street 1:1500 WALNUT ST
Practice Address - Street 2:MZ 05
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3523
Practice Address - Country:US
Practice Address - Phone:215-546-5660
Practice Address - Fax:215-933-3120
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004613L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0500541000OtherINDEPENDENCE BLUE CROSS
PA0500541000OtherINDEPENDENCE BLUE CROSS