Provider Demographics
NPI:1952374597
Name:WAGNER, NOEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:NOEL
Middle Name:DAVID
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 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-2833
Mailing Address - Fax:989-583-1440
Practice Address - Street 1:900 COOPER AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5182
Practice Address - Country:US
Practice Address - Phone:989-583-6521
Practice Address - Fax:989-583-4134
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093040207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162798602Medicaid
MI1952374597Medicaid
TX162798602Medicaid
TX8D9440Medicare PIN
G97970Medicare UPIN