Provider Demographics
NPI:1578690178
Name:WAGNER, RAMAH J (DC)
Entity Type:Individual
Prefix:DR
First Name:RAMAH
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 S BAY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6501
Mailing Address - Country:US
Mailing Address - Phone:352-589-5443
Mailing Address - Fax:352-589-5549
Practice Address - Street 1:2755 S BAY ST
Practice Address - Street 2:SUITE D
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6587
Practice Address - Country:US
Practice Address - Phone:352-589-5443
Practice Address - Fax:352-589-5549
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8955111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96871OtherBLUE CROSS BLUE SHIELD FL
FL96871OtherBLUE CROSS BLUE SHIELD FL
FLV08081Medicare UPIN
FL96871ZMedicare PIN