Provider Demographics
NPI:1972568293
Name:WAGNER, ROBERT CLARK (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLARK
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 1:1635 N GEORGE MASON DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3601
Mailing Address - Country:US
Mailing Address - Phone:703-243-7677
Mailing Address - Fax:703-243-5416
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:SUITE 140
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3601
Practice Address - Country:US
Practice Address - Phone:703-243-7677
Practice Address - Fax:703-243-5416
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101030296174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7393202Medicaid
VAC61551Medicare UPIN
VA7393202Medicaid