Provider Demographics
NPI:1477633931
Name:WAGNER, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5 EAST 98TH STREET BOX 1170
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:212-241-5681
Mailing Address - Fax:212-348-7438
Practice Address - Street 1:1176 FIFITH AVENUE E LEVEL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-659-8557
Practice Address - Fax:212-369-2385
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225630207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02532754Medicaid