Provider Demographics
NPI:1750444279
Name:WAGH, SUJATA M (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJATA
Middle Name:M
Last Name:WAGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9695 S YOSEMITE ST STE 285
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-2890
Mailing Address - Country:US
Mailing Address - Phone:303-649-3115
Mailing Address - Fax:303-649-3116
Practice Address - Street 1:9695 S YOSEMITE ST STE 285
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-2890
Practice Address - Country:US
Practice Address - Phone:303-649-3115
Practice Address - Fax:303-649-3116
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114735207RE0101X
FLME100852207RE0101X
CODR.0055911207RE0101X
CO0055911207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL29334OtherBCBS FL
FL000576000Medicaid
FL000576000Medicaid
FLAK458XMedicare PIN
FL29334OtherBCBS FL