Provider Demographics
NPI:1558312579
Name:WAGNER, ELLIOTT JAY (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:JAY
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 1:200 EAST 66TH ST
Mailing Address - Street 2:C904
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-9175
Mailing Address - Country:US
Mailing Address - Phone:888-886-5238
Mailing Address - Fax:888-886-9330
Practice Address - Street 1:200 E 66TH ST APT C904
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-0163
Practice Address - Country:US
Practice Address - Phone:949-378-4889
Practice Address - Fax:212-752-2190
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238657-12085R0202X
NJ25MA081221002085R0202X
NMMD2008-07772085R0202X
CAG496982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G496980OtherBLUE SHIELD
CA00G496980Medicaid
NY02917751Medicaid
A51438Medicare UPIN
NY02917751Medicaid
CA300016066Medicare PIN