Provider Demographics
NPI:1881684207
Name:WAGNER, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:98 WILLOW LN
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1357
Practice Address - Country:US
Practice Address - Phone:864-585-5552
Practice Address - Fax:864-597-0179
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16033207K00000X
SCMD16033207K00000X
NC35781207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1235321233Medicaid
SCE593334292OtherMEDICARE PTAN
SC160337Medicaid
NC2174958BOtherMEDICARE PTAN
NC85201OtherBCBS
SC56220OtherMEDCOST
SC6554OtherAETNA
NC8985201Medicaid
SC6554OtherAETNA
SC160337Medicaid