Provider Demographics
NPI:1326030586
Name:WAGSTAFF, DONNA M (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:WAGSTAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:M
Other - Last Name:ANDRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4438 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-3316
Mailing Address - Country:US
Mailing Address - Phone:314-543-5996
Mailing Address - Fax:314-543-5958
Practice Address - Street 1:4438 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3316
Practice Address - Country:US
Practice Address - Phone:314-543-5996
Practice Address - Fax:314-543-5958
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156880001OtherMEDICARE PTAN #
MOH07025Medicare UPIN