Provider Demographics
NPI:1609860519
Name:WAGMAN, JOEL I (MD)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:I
Last Name:WAGMAN
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 1:251 E BRINGHURST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-1719
Mailing Address - Country:US
Mailing Address - Phone:215-844-1020
Mailing Address - Fax:215-844-2702
Practice Address - Street 1:251 E BRINGHURST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-1719
Practice Address - Country:US
Practice Address - Phone:215-844-1020
Practice Address - Fax:215-844-2702
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9291207Q00000X
PAMD051924L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007564460003Medicaid
PA391960OtherMEDICARE FQHC
PA391960OtherMEDICARE FQHC