Provider Demographics
NPI:1255419511
Name:WAGNER, WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:MPG DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5663
Mailing Address - Fax:954-276-0301
Practice Address - Street 1:6214 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-5932
Practice Address - Country:US
Practice Address - Phone:954-967-2500
Practice Address - Fax:954-967-2511
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50930207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME50930OtherLICENSE
FL262317000Medicaid