Provider Demographics
NPI:1740074699
Name:WAGNER, MARK BRIAN (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BRIAN
Last Name:WAGNER
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5540 OSO PKWY APT 14
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-6226
Mailing Address - Country:US
Mailing Address - Phone:361-658-9684
Mailing Address - Fax:
Practice Address - Street 1:500 W MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4220
Practice Address - Country:US
Practice Address - Phone:281-332-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program