Provider Demographics
NPI:1790893022
Name:WAGNER, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:WAGNER
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 1:460 HARTFORD TPKE STE A
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4847
Mailing Address - Country:US
Mailing Address - Phone:860-896-4877
Mailing Address - Fax:860-896-4876
Practice Address - Street 1:460 HARTFORD TPKE STE A
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4847
Practice Address - Country:US
Practice Address - Phone:860-896-4877
Practice Address - Fax:860-896-4876
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47653207R00000X
CT50129207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34678700Medicaid
I39760Medicare UPIN
WI34678700Medicaid
WI091172200Medicare ID - Type Unspecified