Healthcare Provider Details

I. General information

NPI: 1730561275
Provider Name (Legal Business Name): JUSTIN WAGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2015
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL MEDICAL PKWY STE 100
PALM COAST FL
32164-5979
US

IV. Provider business mailing address

1 MEMORIAL MEDICAL PKWY STE 100
PALM COAST FL
32164
US

V. Phone/Fax

Practice location:
  • Phone: 386-586-2060
  • Fax: 386-586-4659
Mailing address:
  • Phone: 386-586-2060
  • Fax: 386-586-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number174621
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number263230
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: