Provider Demographics
NPI:1750348314
Name:WAGNER, DANIEL B (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:B
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 HARRIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4245
Mailing Address - Country:US
Mailing Address - Phone:817-877-3432
Mailing Address - Fax:817-346-4394
Practice Address - Street 1:6301 HARRIS PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4245
Practice Address - Country:US
Practice Address - Phone:817-877-3432
Practice Address - Fax:817-346-4394
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6450207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00444159OtherRAIL ROAD MEDICARE
TX175143005Medicaid
TX330144201Medicaid
TX175143005Medicaid
TX330652YKPWMedicare PIN