Provider Demographics
NPI:1407854284
Name:WAGNER, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:88 MCGREGOR ST
Mailing Address - Street 2:STE 303
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-3750
Mailing Address - Country:US
Mailing Address - Phone:603-647-9325
Mailing Address - Fax:603-647-2453
Practice Address - Street 1:88 MCGREGOR ST
Practice Address - Street 2:STE 303
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3750
Practice Address - Country:US
Practice Address - Phone:603-647-9325
Practice Address - Fax:603-647-2453
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2014-03-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NH6750207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30002238Medicaid
NH30002238Medicaid
NHNH9829Medicare PIN