Provider Demographics
NPI:1134248867
Name:WAGNER, DONALD J (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:J
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 1:1355 RAMAR RD
Mailing Address - Street 2:STE 11
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7100
Mailing Address - Country:US
Mailing Address - Phone:928-704-7202
Mailing Address - Fax:928-704-9207
Practice Address - Street 1:1355 RAMAR RD
Practice Address - Street 2:STE 11
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7100
Practice Address - Country:US
Practice Address - Phone:928-704-7202
Practice Address - Fax:928-704-9207
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3719207Q00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ76323Medicare PIN