Provider Demographics
NPI:1801853734
Name:WAGNER, JOSEPH BURRELL (BS;MD;DC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:BURRELL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:BS;MD;DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 N RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2170
Mailing Address - Country:US
Mailing Address - Phone:386-258-7494
Mailing Address - Fax:386-253-0365
Practice Address - Street 1:542 N RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2170
Practice Address - Country:US
Practice Address - Phone:386-258-7494
Practice Address - Fax:386-253-0365
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3009111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88276Medicare PIN
FL88276Medicare UPIN