Provider Demographics
NPI:1831162791
Name:WAGNER, THEODORE T III (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:T
Last Name:WAGNER
Suffix:III
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 325
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1714
Practice Address - Country:US
Practice Address - Phone:260-425-5400
Practice Address - Fax:260-425-5417
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050471A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100081380Medicaid
OH0748972Medicaid
IN000000087512OtherANTHEM BC/BS
IN200245650Medicaid
OH2568556Medicaid
OH0748972Medicaid
IN136140OMedicare PIN
IN150640PPPMedicare PIN
IN200245650Medicaid
IN100081380Medicaid
INCB9217Medicare PIN
OHDG2339Medicare PIN
IN000000087512OtherANTHEM BC/BS
ING97687Medicare UPIN
OH9928923Medicare PIN