Provider Demographics
NPI:1568457778
Name:WAGNER, LEONARD Y (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:Y
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:PO BOX 9135
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9135
Mailing Address - Country:US
Mailing Address - Phone:603-893-9784
Mailing Address - Fax:603-893-8886
Practice Address - Street 1:299 CAREW ST
Practice Address - Street 2:SUITE 409
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2301
Practice Address - Country:US
Practice Address - Phone:413-734-3476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47835207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB33635OtherBLUE CROSS
MA0143863Medicaid
2000048002Medicare PIN
B99552Medicare UPIN
MA0143863Medicaid
MAB33635Medicare PIN