Provider Demographics
NPI:1780758003
Name:WAGAMON, KYLE L (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:L
Last Name:WAGAMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19301 CYCLONE DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-1731
Mailing Address - Country:US
Mailing Address - Phone:330-393-4000
Mailing Address - Fax:330-392-5870
Practice Address - Street 1:2660 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6204
Practice Address - Country:US
Practice Address - Phone:330-393-4000
Practice Address - Fax:330-392-5870
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083746207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7474933OtherAETNA
OH000000217451OtherUNISON
OHP00406585OtherRAILROAD MEDICARE
OH415051OtherWELLCARE
OH000000527821OtherANTHEM
OH2754827Medicaid
OH748956OtherBUCKEYE
OH7474933OtherAETNA
OH2754827Medicaid