Provider Demographics
NPI:1568435741
Name:WAGNER, EDWARD STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:STEVEN
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 1:4330 SHERIDAN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021
Mailing Address - Country:US
Mailing Address - Phone:954-962-9802
Mailing Address - Fax:954-962-2233
Practice Address - Street 1:4330 SHERIDAN ST
Practice Address - Street 2:STE 101
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-962-9802
Practice Address - Fax:954-962-2233
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68203207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379684100Medicaid
G08491Medicare UPIN
FL27122WMedicare ID - Type Unspecified