Provider Demographics
NPI:1538120704
Name:WAGNER, JOHN RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:WAGNER
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 1:7 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2442
Mailing Address - Country:US
Mailing Address - Phone:631-261-3322
Mailing Address - Fax:631-368-5440
Practice Address - Street 1:7 PULASKI RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-2442
Practice Address - Country:US
Practice Address - Phone:631-261-3322
Practice Address - Fax:631-368-5440
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181212207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01280253Medicaid
E87551Medicare UPIN
NY78F481Medicare ID - Type Unspecified