Healthcare Provider Details

I. General information

NPI: 1356801237
Provider Name (Legal Business Name): SCOTT FORBES WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 LEOMINSTER RD
STERLING MA
01564-2148
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-5348
US

V. Phone/Fax

Practice location:
  • Phone: 978-422-6900
  • Fax: 978-422-7561
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number292441
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: