Healthcare Provider Details

I. General information

NPI: 1003858952
Provider Name (Legal Business Name): RICHARD KENT WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8085
US

IV. Provider business mailing address

263 FARMINGTON AVENUE
FARMINGTON CT
06030-8085
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-3387
  • Fax: 860-679-1494
Mailing address:
  • Phone: 860-679-3387
  • Fax: 860-679-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number67319
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number67319
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: