Healthcare Provider Details

I. General information

NPI: 1508836123
Provider Name (Legal Business Name): DAVID V WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 PIERCE ST SUITE 204
SIOUX CITY IA
51104-3796
US

IV. Provider business mailing address

2730 PIERCE ST SUITE 204
SIOUX CITY IA
51104-3796
US

V. Phone/Fax

Practice location:
  • Phone: 712-234-8787
  • Fax: 712-234-8777
Mailing address:
  • Phone: 712-234-8787
  • Fax: 712-234-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number29266
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: