Provider Demographics
NPI:1447603220
Name:WAGNER, JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
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:NMRTC CAMP PENDLETON
Mailing Address - Street 2:4TH FLOOR, RM 4172
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-725-1288
Mailing Address - Fax:
Practice Address - Street 1:NMRTC CAMP PENDLETON
Practice Address - Street 2:4TH FLOOR, RM 4172
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133693207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN