Healthcare Provider Details

I. General information

NPI: 1578913786
Provider Name (Legal Business Name): VINCENT M WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2016
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR DEPT OF OBSTETRICS AND GYNECOLOGY
IOWA CITY IA
52242-1009
US

IV. Provider business mailing address

200 HAWKINS DR DEPT OF OBSTETRICS AND GYNECOLOGY
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-2294
  • Fax: 319-384-9693
Mailing address:
  • Phone: 319-356-2294
  • Fax: 319-384-9693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD-51803
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD-51803
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: