Provider Demographics
NPI:1487634085
Name:WAGNER, JOHN H III (MD, CMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:WAGNER
Suffix:III
Gender:M
Credentials:MD, CMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:401 ARNOLD STREET NE
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-0339
Mailing Address - Country:US
Mailing Address - Phone:256-739-9593
Mailing Address - Fax:256-739-2984
Practice Address - Street 1:401 ARNOLD ST NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-1968
Practice Address - Country:US
Practice Address - Phone:256-739-9593
Practice Address - Fax:256-739-2984
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8613208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051551301OtherBC/BS OF ALABAMA
AL009935241Medicaid
AL010066311OtherMETRA RAILROAD MEDICARE
AL51027867OtherBC/BS OF ALABAMA
AL000027867Medicaid
AL000027867WAGMedicare PIN
AL000027867Medicaid
C72882Medicare UPIN