Provider Demographics
NPI:1184753782
Name:WAGNER, JAMES L (MD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:L
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6900 PEARL ROAD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3639
Mailing Address - Country:US
Mailing Address - Phone:440-845-0900
Mailing Address - Fax:440-845-7355
Practice Address - Street 1:6900 PEARL ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3639
Practice Address - Country:US
Practice Address - Phone:440-845-0900
Practice Address - Fax:440-845-7355
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052657207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2152138Medicaid
OH2152138Medicaid
OHWA0896591Medicare ID - Type Unspecified