Provider Demographics
NPI:1477187383
Name:WAGNER, ROY MARSHALL (DO)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:MARSHALL
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1284
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:618-206-2332
Practice Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269
Practice Address - Country:US
Practice Address - Phone:618-233-7880
Practice Address - Fax:618-222-4792
Is Sole Proprietor?:No
Enumeration Date:2020-02-29
Last Update Date:2023-11-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036164627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine