Provider Demographics
NPI:1851372619
Name:WAGNER, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
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:PO BOX 965
Mailing Address - Street 2:
Mailing Address - City:SHINER
Mailing Address - State:TX
Mailing Address - Zip Code:77984-0965
Mailing Address - Country:US
Mailing Address - Phone:361-594-3824
Mailing Address - Fax:361-594-4104
Practice Address - Street 1:124 E WOLTERS 2ND
Practice Address - Street 2:
Practice Address - City:SHINER
Practice Address - State:TX
Practice Address - Zip Code:77984-7109
Practice Address - Country:US
Practice Address - Phone:361-594-3824
Practice Address - Fax:361-594-4104
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135624802Medicaid
TX836T776OtherBLUE CROSS
TX82Y592OtherBC
E95914Medicare UPIN
TX135624802Medicaid