Provider Demographics
NPI:1437147683
Name:WAGNER, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 GERMAN ST
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9349
Mailing Address - Country:US
Mailing Address - Phone:989-362-4170
Mailing Address - Fax:989-362-0034
Practice Address - Street 1:700 GERMAN ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9349
Practice Address - Country:US
Practice Address - Phone:989-362-4170
Practice Address - Fax:989-362-0034
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2862730Medicaid
A78602Medicare UPIN
MIC56012003Medicare ID - Type Unspecified