Provider Demographics
NPI:1609079607
Name:JEFFREY D. WAGNER, MD, PC
Entity Type:Organization
Organization Name:JEFFREY D. WAGNER, MD, PC
Other - Org Name:WAGNER AND ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-621-2520
Mailing Address - Street 1:8040 CLEARVISTA PKWY STE 570
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4673
Mailing Address - Country:US
Mailing Address - Phone:317-621-2580
Mailing Address - Fax:
Practice Address - Street 1:8040 CLEARVISTA PKWY STE 570
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4673
Practice Address - Country:US
Practice Address - Phone:317-621-2580
Practice Address - Fax:317-621-2580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF61874Medicare UPIN