Provider Demographics
NPI:1265607741
Name:WAGNER, LAUREN E (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:E
Last Name:WAGNER
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 1:333 E. ONTARIO ST.
Mailing Address - Street 2:SUITE 3303B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-255-8111
Mailing Address - Fax:
Practice Address - Street 1:333 E ONTARIO ST
Practice Address - Street 2:SUITE 3303B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4804
Practice Address - Country:US
Practice Address - Phone:312-255-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1005172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry