Provider Demographics
NPI:1326029885
Name:WAGNER, MARTIN D (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 68952
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0952
Mailing Address - Country:US
Mailing Address - Phone:317-802-6302
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:1515 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3453
Practice Address - Country:US
Practice Address - Phone:317-802-6302
Practice Address - Fax:317-870-0499
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01030508207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN215530CMedicare PIN
C25291Medicare UPIN