Provider Demographics
NPI:1881858959
Name:CONNECTICUT FOOT SPECIALISTS PC
Entity Type:Organization
Organization Name:CONNECTICUT FOOT SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-653-4708
Mailing Address - Street 1:133 HARTFORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:EAST GRANBY
Mailing Address - State:CT
Mailing Address - Zip Code:06026
Mailing Address - Country:US
Mailing Address - Phone:860-653-4708
Mailing Address - Fax:860-653-6249
Practice Address - Street 1:259 ALBANY TURNPIKE
Practice Address - Street 2:SUITE C
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019
Practice Address - Country:US
Practice Address - Phone:860-653-4708
Practice Address - Fax:860-653-6249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093743502OtherNPI # DR. WAGNER
CTCT000793OtherSTATE LICENSE DR. WAGNER
CTCT000793OtherSTATE LICENSE DR. WAGNER
CTCT000793OtherSTATE LICENSE DR. WAGNER