Provider Demographics
NPI:1457391617
Name:WAGNON, CHARLES LEE (MD)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEE
Last Name:WAGNON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:777 E WHEATLAND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116
Mailing Address - Country:US
Mailing Address - Phone:972-298-4981
Mailing Address - Fax:972-298-4984
Practice Address - Street 1:777 E WHEATLAND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116
Practice Address - Country:US
Practice Address - Phone:972-298-4981
Practice Address - Fax:972-298-4984
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXD4346207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B27389Medicare UPIN