Healthcare Provider Details

I. General information

NPI: 1407815038
Provider Name (Legal Business Name): KARLA MONTGOMERY WAGNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KARLA MONTGOMERY-WAGNER

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 LAUREL BUSH RD SUITE H
BEL AIR MD
21015-6156
US

IV. Provider business mailing address

2111 LAUREL BUSH RD SUITE H
BEL AIR MD
21015-6156
US

V. Phone/Fax

Practice location:
  • Phone: 410-569-3300
  • Fax: 410-515-2027
Mailing address:
  • Phone: 410-569-3300
  • Fax: 410-515-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0045592
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: