Provider Demographics
NPI:1578550612
Name:WAGNER, JOSEPH ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ROBERT
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 1:85 SEYMOUR ST
Mailing Address - Street 2:STE 416
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-947-8500
Mailing Address - Fax:860-524-8643
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:STE 416
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-947-8500
Practice Address - Fax:860-524-8643
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041512208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010041512CT01OtherANTHEM BCBS
CT3231961OtherAETNA
MA2020611Medicaid
CT227400OtherWELLCARE
CT001415125Medicaid
CT2V3291OtherHEALTH NET
CT32475OtherHEALTH NEW ENGLAND
CT3528766 009OtherCIGNA
CTP2913141OtherOXFORD
CT2V3291OtherHEALTH NET
CT001415125Medicaid
CT06-1406459OtherCORVEL
CT06-1406459OtherMULTIPLAN
G51240Medicare UPIN
CT001415125Medicaid
CT010041512CT01OtherANTHEM BCBS
CT227400OtherWELLCARE
CT06-1406459OtherFOCUS
CT06-1406459OtherUNITED HEALTHCARE
CT32475OtherHEALTH NEW ENGLAND
CT340000358Medicare PIN