Provider Demographics
NPI:1982658241
Name:WAGNER, BRETT D (DO)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:D
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 ROCKY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-6740
Mailing Address - Country:US
Mailing Address - Phone:704-266-4179
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:800 W MEETING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-2202
Practice Address - Country:US
Practice Address - Phone:803-286-1479
Practice Address - Fax:803-286-1369
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC538207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85135Medicare UPIN