Provider Demographics
NPI:1821052747
Name:WAGNER-REISS, KATHERINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:M
Last Name:WAGNER-REISS
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 1:2800 MAIN ST
Mailing Address - Street 2:ST. VINCENT'S MEDICAL CENTER, DEPT. OF PATHOLOGY
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:203-576-5033
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:ST. VINCENT'S MEDICAL CENTER, DEPT. OF PATHOLOGY
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-576-5033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025577207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001255779Medicaid
CT220000484Medicare ID - Type Unspecified
CTE43103Medicare UPIN