Provider Demographics
NPI:1417904442
Name:WAGSTAFF, DANIEL LEE (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:WAGSTAFF
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24395207R00000X
LA203440208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863071OtherBLUECHOICE HEALTHPLAN ID
SC576007863095OtherBCBS OF SC ID
LA1808580Medicaid
SCP00110891OtherRR MEDICARE
SC5135341OtherCIGNA ID
SC243953Medicaid
MS03427237Medicaid
SC7712588OtherAETNA ID
SCP01577390OtherRAILROAD MEDICARE
SCP01577390OtherRAILROAD MEDICARE
SCSC65915019Medicare PIN
SCP00110891OtherRR MEDICARE
SC243953Medicaid
MS03427237Medicaid
SCSC65919068Medicare PIN