Provider Demographics
NPI:1528043536
Name:WAGNER, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5149 N 9TH AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8734
Mailing Address - Country:US
Mailing Address - Phone:850-477-9253
Mailing Address - Fax:850-494-9843
Practice Address - Street 1:5149 N 9TH AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8734
Practice Address - Country:US
Practice Address - Phone:850-477-9253
Practice Address - Fax:850-494-9843
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0076654207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254788100Medicaid
FLF09970Medicare UPIN
FL44239ZMedicare ID - Type Unspecified