Provider Demographics
NPI:1689609133
Name:WAGNER, MATTHEW GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GEORGE
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 1:11116 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 2989
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11116 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 2989
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6710
Practice Address - Country:US
Practice Address - Phone:301-766-7600
Practice Address - Fax:301-797-4976
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00340152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD425459-02OtherBC/BS ID #
MD001240825 0004OtherPA MEDICAID
MDPVPB125341OtherAPS PROVIDER ID
MD5324319 00Medicaid
MDPVPB125341OtherAPS PROVIDER ID
MDK025528VMedicare ID - Type UnspecifiedMEDICARE GROUP #