Healthcare Provider Details

I. General information

NPI: 1093743502
Provider Name (Legal Business Name): BRIAN KEITH WAGNER D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SOUTH RD LOWR LEVEL20
FARMINGTON CT
06032-2483
US

IV. Provider business mailing address

11 SOUTH ROAD LOWER LEVEL 20
FARMINGTON CT
06032
US

V. Phone/Fax

Practice location:
  • Phone: 860-470-5703
  • Fax: 860-606-8025
Mailing address:
  • Phone: 860-470-5703
  • Fax: 860-606-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000793
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number000793
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000862
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number000793
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: