Provider Demographics
NPI:1316380694
Name:WAGNER, MEREDITH WALL (MD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:WALL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:LYNN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6254 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4713
Mailing Address - Country:US
Mailing Address - Phone:901-624-3333
Mailing Address - Fax:
Practice Address - Street 1:6254 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119
Practice Address - Country:US
Practice Address - Phone:901-624-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.165930207N00000X
CAA146514207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty