Provider Demographics
NPI:1821080201
Name:WAGNER, ARNOLD L JR (MD)
Entity Type:Individual
Prefix:
First Name:ARNOLD
Middle Name:L
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:601 SKOKIE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2820
Mailing Address - Country:US
Mailing Address - Phone:847-562-1410
Mailing Address - Fax:847-562-0830
Practice Address - Street 1:2500 RIDGE AVE STE 311
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2477
Practice Address - Country:US
Practice Address - Phone:847-869-5800
Practice Address - Fax:847-869-9315
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2017-09-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036043335207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK45386Medicare PIN
ILD11351Medicare UPIN
ILK45385Medicare PIN