Provider Demographics
NPI:1942291562
Name:WAGONER, ALAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:L
Last Name:WAGONER
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 1:1309 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-3314
Mailing Address - Country:US
Mailing Address - Phone:765-656-3401
Mailing Address - Fax:765-656-3415
Practice Address - Street 1:1309 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-3314
Practice Address - Country:US
Practice Address - Phone:765-656-3401
Practice Address - Fax:765-656-3415
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2013-03-13
Deactivation Date:2013-01-24
Deactivation Code:
Reactivation Date:2013-03-13
Provider Licenses
StateLicense IDTaxonomies
IN01033827A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100195340AMedicaid
IND69770Medicare UPIN
IN610370Medicare ID - Type Unspecified