Provider Demographics
NPI:1669464673
Name:WAGNER, THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:34960 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:N RIDGEVILLE
Practice Address - State:OH
Practice Address - Zip Code:44039-3183
Practice Address - Country:US
Practice Address - Phone:440-353-3433
Practice Address - Fax:440-353-3431
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00103662OtherRR MEDICARE
OH2253832Medicaid
OH4054155Medicare PIN
OH4054156Medicare PIN
OHP00103662OtherRR MEDICARE