Healthcare Provider Details

I. General information

NPI: 1710928270
Provider Name (Legal Business Name): ANGELA B WAGNER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5926 CRAWFORDSVILLE RD UNIT B
INDIANAPOLIS IN
46224-3722
US

IV. Provider business mailing address

30 W MONROE ST STE 1200
CHICAGO IL
60603-2420
US

V. Phone/Fax

Practice location:
  • Phone: 317-653-2730
  • Fax: 317-321-1935
Mailing address:
  • Phone: 815-861-4302
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number02002402A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02002402A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number02002402A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: