Healthcare Provider Details

I. General information

NPI: 1487989190
Provider Name (Legal Business Name): GABRIEL MICHAEL WAGMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 UNION BLVD
BAY SHORE NY
11706-7921
US

IV. Provider business mailing address

1916 UNION BLVD
BAY SHORE NY
11706-7921
US

V. Phone/Fax

Practice location:
  • Phone: 631-666-2290
  • Fax: 631-647-5299
Mailing address:
  • Phone: 631-666-2290
  • Fax: 631-647-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License Number255002
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RH0005X
TaxonomyHypertension Specialist Physician
License Number255002
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number255002
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number255002
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: