Healthcare Provider Details

I. General information

NPI: 1083848030
Provider Name (Legal Business Name): BRADFORD S. WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 FODEN RD STE 3
SOUTH PORTLAND ME
04106-1718
US

IV. Provider business mailing address

100 GANNETT DR SUITE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1489
  • Fax: 207-523-8590
Mailing address:
  • Phone: 207-828-0361
  • Fax: 207-874-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD19486
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD19486
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: