Provider Demographics
NPI:1487630414
Name:WAGEL, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:WAGEL
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:# 774560, 4560 SOLUTIONS CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-4005
Mailing Address - Country:US
Mailing Address - Phone:260-969-1950
Mailing Address - Fax:260-918-2137
Practice Address - Street 1:1316 E 7TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2523
Practice Address - Country:US
Practice Address - Phone:260-925-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040117A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00266379OtherRAILROAD MEDICARE
IN100318150AMedicaid
IN0000372545OtherBC/BS
IN180190CCMedicare PIN
INP00266379OtherRAILROAD MEDICARE