Healthcare Provider Details

I. General information

NPI: 1992751036
Provider Name (Legal Business Name): DANIEL R. WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 09/21/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11188 TESSON FERRY RD STE 202
SAINT LOUIS MO
63123-6962
US

IV. Provider business mailing address

11888 TESSON FERRY RD. STE. 202
ST. LOUIS MO
63123
US

V. Phone/Fax

Practice location:
  • Phone: 314-729-7547
  • Fax: 314-729-7547
Mailing address:
  • Phone: 314-729-7547
  • Fax: 314-729-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2007009239
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number129759
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: