Provider Demographics
NPI:1023317898
Name:WAGNER, MICHAEL J
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5450
Mailing Address - Country:US
Mailing Address - Phone:617-632-5204
Mailing Address - Fax:617-632-3408
Practice Address - Street 1:450 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5450
Practice Address - Country:US
Practice Address - Phone:617-632-5204
Practice Address - Fax:617-632-3408
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016422207RX0202X
WAMD60759395207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1023317898Medicaid
WAG8968128OtherMEDICARE PIN
WA1023317898Medicaid
TX342203201Medicaid