Provider Demographics
NPI:1811077894
Name:WAGNER, THEODORE A (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:A
Last Name:WAGNER
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:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:UWMC-ROOSEVELT
Practice Address - Street 2:4245 ROOSEVELT WAY NE
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4740
Practice Address - Country:US
Practice Address - Phone:206-598-4288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00011315207X00000X, 207XP3100X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0232121OtherL&I
9054OtherINTERNAL ID-MOTOR VEHICLE ID
WA1811077894Medicaid
WA8804991Medicare PIN
WA1811077894Medicaid