Provider Demographics
NPI:1891755252
Name:WAGONER, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-447-4165
Mailing Address - Fax:765-447-6978
Practice Address - Street 1:1411 S CREASY LN
Practice Address - Street 2:SUITE 120
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7433
Practice Address - Country:US
Practice Address - Phone:765-447-4165
Practice Address - Fax:765-447-6978
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01020202A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC25690Medicare UPIN
IN815010EMedicare ID - Type Unspecified