Provider Demographics
NPI:1326338989
Name:MITCHELL S WAGNER MD PLLC
Entity Type:Organization
Organization Name:MITCHELL S WAGNER MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-903-0443
Mailing Address - Street 1:60 E RIO SALADO PKWY
Mailing Address - Street 2:STE 505
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-9128
Mailing Address - Country:US
Mailing Address - Phone:602-903-0443
Mailing Address - Fax:480-777-1345
Practice Address - Street 1:60 E RIO SALADO PKWY
Practice Address - Street 2:STE 505
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-9128
Practice Address - Country:US
Practice Address - Phone:602-903-0443
Practice Address - Fax:480-777-1345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27272207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6570280001Medicare NSC