Provider Demographics
NPI:1942248570
Name:WAGNER, CODY L (MD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:L
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 1:718 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-1348
Mailing Address - Country:US
Mailing Address - Phone:812-662-0588
Mailing Address - Fax:812-663-5932
Practice Address - Street 1:718 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-1348
Practice Address - Country:US
Practice Address - Phone:812-662-0588
Practice Address - Fax:812-663-5932
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200123810AMedicaid
IN200123810AMedicaid
IN192590WMedicare ID - Type Unspecified