Provider Demographics
NPI:1821409343
Name:ABRAHAM WAGNER DPM PA
Entity Type:Organization
Organization Name:ABRAHAM WAGNER DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:305-652-6676
Mailing Address - Street 1:21097 NE 27TH CT
Mailing Address - Street 2:SUITE 200B
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1204
Mailing Address - Country:US
Mailing Address - Phone:305-652-6676
Mailing Address - Fax:305-932-6335
Practice Address - Street 1:8600 SW 92ND ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-7397
Practice Address - Country:US
Practice Address - Phone:305-652-6676
Practice Address - Fax:305-932-6335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3262213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty