Provider Demographics
NPI:1457329997
Name:WAGNER, ROBERT HARRISON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HARRISON
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 1:11350 MCCORMICK ROAD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:8501 ARLINGTON BLVD STE 410
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-738-4331
Practice Address - Fax:703-642-1876
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054689208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6801765Medicaid
VA6801765Medicaid
VAG97491Medicare UPIN