Provider Demographics
NPI:1326033572
Name:WAGNER, CRAIG R (DO ANESTHESIOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO ANESTHESIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1617
Mailing Address - Country:US
Mailing Address - Phone:856-845-0100
Mailing Address - Fax:856-848-7023
Practice Address - Street 1:509 N BROAD ST
Practice Address - Street 2:UNDERWOOD HOSP
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-845-5836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NJ25MB05214300207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1442007Medicaid
NJ25MB05214300OtherMEDICAL LICENSE
NJD04881500OtherCDS
NJD04881500OtherCDS
NJ1442007Medicaid
BW1551933OtherDEA