Provider Demographics
NPI:1407977119
Name:WAGNER, CLIFF W (MD)
Entity Type:Individual
Prefix:DR
First Name:CLIFF
Middle Name:W
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 1:2909 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4115
Mailing Address - Country:US
Mailing Address - Phone:860-436-3757
Mailing Address - Fax:860-436-9622
Practice Address - Street 1:2909 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4115
Practice Address - Country:US
Practice Address - Phone:860-436-3757
Practice Address - Fax:860-436-9622
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030264207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D88722Medicare UPIN
D88722Medicare UPIN
CT004167111Medicaid
110220674OtherRAILROAD MEDICARE
CT1139270001Medicare ID - Type Unspecified