Provider Demographics
NPI:1912931619
Name:WAGNER, PHILLIP LEROY (MD)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:LEROY
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 1:1220 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3910
Mailing Address - Country:US
Mailing Address - Phone:707-246-5744
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:OCCUPATIONAL MEDICINE
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-2243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM200600832083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ087585Medicaid
A44236Medicare UPIN