Provider Demographics
NPI:1376509687
Name:WAGNER, RICK JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:JOSEPH
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E 8TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-2633
Mailing Address - Country:US
Mailing Address - Phone:605-842-1612
Mailing Address - Fax:605-842-3837
Practice Address - Street 1:825 E 8TH ST STE 202
Practice Address - Street 2:
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2633
Practice Address - Country:US
Practice Address - Phone:605-842-1612
Practice Address - Fax:605-842-3837
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4183208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD41831OtherDAKOTACARE
NE460381151-13Medicaid
SD7301542Medicaid
SD25420OtherSANFORD HEALTH PLAN
SD4992949OtherWELLMARK BC/BS
SD25420OtherSANFORD HEALTH PLAN
F78147Medicare UPIN
SD41831OtherDAKOTACARE
SDS101960Medicare PIN