Provider Demographics
NPI:1598738155
Name:WAGNER, WILLIAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:WAGNER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:90 HEALTH PARK DR
Mailing Address - Street 2:SUITE 390
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-9757
Mailing Address - Country:US
Mailing Address - Phone:303-426-0215
Mailing Address - Fax:303-426-4003
Practice Address - Street 1:90 HEALTH PARK DR
Practice Address - Street 2:SUITE 390
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9757
Practice Address - Country:US
Practice Address - Phone:303-426-0215
Practice Address - Fax:303-426-4003
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2011-12-20
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Provider Licenses
StateLicense IDTaxonomies
CO373992084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF94420Medicare UPIN
COCA0948Medicare PIN