Healthcare Provider Details

I. General information

NPI: 1841982709
Provider Name (Legal Business Name): MATTHEW JOHN WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 W 110TH ST APT 1E
NEW YORK NY
10025-2021
US

IV. Provider business mailing address

535 W 110TH ST APT 1E
NEW YORK NY
10025-2021
US

V. Phone/Fax

Practice location:
  • Phone: 212-280-4740
  • Fax: 212-280-4743
Mailing address:
  • Phone: 212-280-4740
  • Fax: 212-280-4743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number344001-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: