Provider Demographics
NPI:1245393529
Name:WAGONER, JOHN HARVEY (MD, PHD, MBA)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HARVEY
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD, PHD, MBA
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Mailing Address - Street 1:133 OLD SOLOMONS ISLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-266-9747
Mailing Address - Fax:410-266-9749
Practice Address - Street 1:133 OLD SOLOMONS ISLAND ROAD
Practice Address - Street 2:BAYSHORE COUNSELING AND PSYCHOLOGICAL SERVICES, LLC
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-266-9747
Practice Address - Fax:410-266-9749
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-12-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MD03283103T00000X
MDD480792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD54297601OtherBCBS OF MD