Provider Demographics
NPI:1184613663
Name:CARTER, ELIZABETH WAGNER (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:WAGNER
Last Name:CARTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4804
Mailing Address - Country:US
Mailing Address - Phone:817-702-7301
Mailing Address - Fax:
Practice Address - Street 1:1400 S MAIN ST
Practice Address - Street 2:LIFESPAN CLINIC
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4909
Practice Address - Country:US
Practice Address - Phone:817-702-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D9014OtherMEDICARE
TXC14256Medicare UPIN