Provider Demographics
NPI:1669514675
Name:WAGNER, ROGER ALAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DRIVE
Mailing Address - Street 2:FALK CVRC
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305
Mailing Address - Country:US
Mailing Address - Phone:650-736-0640
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DRIVE
Practice Address - Street 2:FALK CVRC
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305
Practice Address - Country:US
Practice Address - Phone:650-736-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73669207RC0000X
CO36853207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease