Provider Demographics
NPI:1609812007
Name:WAGNER, RANDALL P (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:P
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 1:1300 PICCARD DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-4303
Mailing Address - Country:US
Mailing Address - Phone:301-921-7900
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:WASHINGTON ADVENTIST HOSPITAL
Practice Address - Street 2:7600 CARROLL AVENUE
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912
Practice Address - Country:US
Practice Address - Phone:301-891-5957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00044957207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A99168Medicare UPIN
MD002760M60Medicare ID - Type Unspecified