Healthcare Provider Details

I. General information

NPI: 1225105695
Provider Name (Legal Business Name): MARTHA WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 K ST NW SUITE 401
WASHINGTON DC
20037-1810
US

IV. Provider business mailing address

2141 K ST NW SUITE 401
WASHINGTON DC
20037-1810
US

V. Phone/Fax

Practice location:
  • Phone: 202-833-4543
  • Fax: 202-833-8977
Mailing address:
  • Phone: 202-833-4543
  • Fax: 202-833-8977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD25902
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: