Provider Demographics
NPI:1255438701
Name:HAROLD WAGNER DO PA
Entity type:Organization
Organization Name:HAROLD WAGNER DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:G
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-434-4031
Mailing Address - Street 1:7441 MARVIN D LOVE FWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3490
Mailing Address - Country:US
Mailing Address - Phone:972-572-1998
Mailing Address - Fax:942-572-4842
Practice Address - Street 1:7441 MARVIN D LOVE FWY
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3490
Practice Address - Country:US
Practice Address - Phone:972-572-1998
Practice Address - Fax:942-572-4842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1754905 01Medicaid
TXDC9723OtherRAILROAD MEDICARE
TX1754905 01Medicaid