Provider Demographics
NPI:1467636951
Name:WAGENMAN, BENJAMIN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LEE
Last Name:WAGENMAN
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 1:1100 CENTRAL AVE SE
Mailing Address - Street 2:PHS- LAB - S1 LEVEL
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4930
Mailing Address - Country:US
Mailing Address - Phone:505-841-1330
Mailing Address - Fax:
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:PHS- LAB - S1 LEVEL
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0037207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology