Provider Demographics
NPI:1811939895
Name:WAGNER, JULIE A (MD)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
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 631568
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14A MOUNT CARMEL RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120-9721
Practice Address - Country:US
Practice Address - Phone:410-357-9283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63852207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409650900Medicaid
G53906Medicare UPIN
MDP00395793Medicare PIN
MD725LN509Medicare PIN