Provider Demographics
NPI:1548202427
Name:WAGNER, KURT B (MD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:B
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 1:1749 DAVID WALKER DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5745
Mailing Address - Country:US
Mailing Address - Phone:352-742-1760
Mailing Address - Fax:352-742-2604
Practice Address - Street 1:1749 DAVID WALKER DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5745
Practice Address - Country:US
Practice Address - Phone:352-742-1760
Practice Address - Fax:352-742-2604
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066638600Medicaid
FL35186OtherBCBS
010053499OtherRAILROAD MEDICARE
D54353Medicare UPIN
FL35186XMedicare PIN