Provider Demographics
NPI:1376680876
Name:WAGNER, STEPHANIE ANN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
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:PO BOX 44994
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46244-0994
Mailing Address - Country:US
Mailing Address - Phone:317-274-4402
Mailing Address - Fax:317-278-1302
Practice Address - Street 1:535 BARNHILL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5116
Practice Address - Country:US
Practice Address - Phone:317-944-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38720207RH0003X
IN01065554A207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000991170OtherANTHEM PIN
KY50020098OtherPASSPORT
KY7100058720Medicaid
IN200911200Medicaid
IN129980CCMedicare PIN
KY0299044Medicare PIN
IN200911200Medicaid
KY50020098OtherPASSPORT
KY7100058720Medicaid