Provider Demographics
NPI:1891880191
Name:WAGNER, DANIEL GRAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GRAY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:224 S WOODS MILL RD
Mailing Address - Street 2:SUITE 750
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3451
Mailing Address - Country:US
Mailing Address - Phone:314-576-9797
Mailing Address - Fax:314-469-7517
Practice Address - Street 1:224 S WOODS MILL RD
Practice Address - Street 2:SUITE 750
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3451
Practice Address - Country:US
Practice Address - Phone:314-576-9797
Practice Address - Fax:314-469-7517
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-04-21
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Provider Licenses
StateLicense IDTaxonomies
MO103423207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206878605Medicaid
MO206878605Medicaid
MOF57142Medicare UPIN