Provider Demographics
NPI:1710928270
Name:WAGNER, ANGELA B (DO)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:B
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MONROE ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2420
Mailing Address - Country:US
Mailing Address - Phone:815-861-4302
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:5926 CRAWFORDSVILLE RD UNIT B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3722
Practice Address - Country:US
Practice Address - Phone:317-653-2730
Practice Address - Fax:317-321-1935
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002402A204D00000X, 207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200411540CMedicaid
IN200411540Medicaid
IN200411540CMedicaid
IN200411540Medicaid