Provider Demographics
NPI:1700965324
Name:WAGONER, GREGORY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:119 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-1004
Mailing Address - Country:US
Mailing Address - Phone:617-964-5754
Mailing Address - Fax:617-414-7776
Practice Address - Street 1:729 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2318
Practice Address - Country:US
Practice Address - Phone:617-414-7779
Practice Address - Fax:617-414-7776
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA38544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB72990Medicare UPIN
MAB33492Medicare ID - Type Unspecified