Provider Demographics
NPI:1821098351
Name:WAGNER, JOHN THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 MOUNT ROYAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15223-1244
Mailing Address - Country:US
Mailing Address - Phone:412-492-9006
Mailing Address - Fax:412-492-0938
Practice Address - Street 1:819 MOUNT ROYAL BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15223-1244
Practice Address - Country:US
Practice Address - Phone:412-492-9006
Practice Address - Fax:412-492-0938
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003667R213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001408328009Medicaid
PA001408328009Medicaid
PAU31602Medicare UPIN