Provider Demographics
NPI:1639114499
Name:WAGSTAFF, BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WAGSTAFF
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 1:1501 GOVERNMENT RD
Mailing Address - Street 2:KEY WEST URGENT CARE
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-5108
Mailing Address - Country:US
Mailing Address - Phone:305-295-7550
Mailing Address - Fax:305-296-3010
Practice Address - Street 1:1501 GOVERNMENT RD
Practice Address - Street 2:KEY WEST URGENT CARE
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-5108
Practice Address - Country:US
Practice Address - Phone:305-295-7550
Practice Address - Fax:305-296-3010
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME92309OtherMD
FLME92309OtherMD