Provider Demographics
NPI:1356302426
Name:WAGNER, DOUGLAS SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:SCOTT
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 1:3925 EMBASSY PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-1799
Mailing Address - Country:US
Mailing Address - Phone:330-668-4065
Mailing Address - Fax:330-668-4082
Practice Address - Street 1:3925 EMBASSY PKWY STE 300
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-1799
Practice Address - Country:US
Practice Address - Phone:330-668-4065
Practice Address - Fax:330-668-4082
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.048046208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0551764Medicaid
OHA17729Medicare UPIN
OH0551764Medicaid