Provider Demographics
NPI:1447212907
Name:WAGONER, DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:WAGONER
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-8600
Mailing Address - Fax:704-384-8610
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:SUITE 501
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2027
Practice Address - Country:US
Practice Address - Phone:704-384-8600
Practice Address - Fax:704-384-8610
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17453208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985210Medicaid
NC8985210Medicaid
NC203309AMedicare ID - Type Unspecified