Healthcare Provider Details

I. General information

NPI: 1104141654
Provider Name (Legal Business Name): DEANNA MARIE WAGNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEANNA MARIE SIKORSKI M.D.

II. Dates (important events)

Enumeration Date: 03/27/2010
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39533 WOODWARD AVE # 155
BLOOMFIELD HILLS MI
48304-5188
US

IV. Provider business mailing address

200 HEALTH PARK DR
OWOSSO MI
48867-1291
US

V. Phone/Fax

Practice location:
  • Phone: 833-322-3376
  • Fax: 248-607-6777
Mailing address:
  • Phone: 989-723-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301102748
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: