Healthcare Provider Details

I. General information

NPI: 1811129547
Provider Name (Legal Business Name): DAVID RUSSELL WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

253 W 72ND ST APT 1703
NEW YORK NY
10023-2709
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5717
  • Fax:
Mailing address:
  • Phone: 702-994-2479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number270163
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: