Healthcare Provider Details

I. General information

NPI: 1164419081
Provider Name (Legal Business Name): ROBERT J WAGNER JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 ALLENTOWN RD SUITE 502
CAMP SPRINGS MD
20746
US

IV. Provider business mailing address

5801 ALLENTOWN RD SUITE 502
CAMP SPRINGS MD
20746-4563
US

V. Phone/Fax

Practice location:
  • Phone: 240-427-1630
  • Fax: 240-492-2070
Mailing address:
  • Phone: 240-427-1630
  • Fax: 240-492-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberH0061922
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH0061922
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: