Provider Demographics
NPI:1619263241
Name:WAGNER, ERIC R (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:R
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 1:59 EXECUTIVE PARK S STE 2000
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2208
Mailing Address - Country:US
Mailing Address - Phone:404-778-7249
Mailing Address - Fax:
Practice Address - Street 1:59 EXECUTIVE PARK S STE 2000
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2208
Practice Address - Country:US
Practice Address - Phone:404-778-7249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA081317207XS0106X
MA269905207X00000X
MN55500207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN200003317Medicare PIN