Provider Demographics
NPI:1962497370
Name:WAGE, MICHAEL L (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:WAGE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 N BRIARCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2842
Mailing Address - Country:US
Mailing Address - Phone:920-730-0160
Mailing Address - Fax:
Practice Address - Street 1:1411 N BRIARCLIFF DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2842
Practice Address - Country:US
Practice Address - Phone:920-730-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25737207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31577700Medicaid
WI0555 45300Medicare PIN
WI0193 71018Medicare PIN
E96066Medicare UPIN