Healthcare Provider Details

I. General information

NPI: 1437244050
Provider Name (Legal Business Name): JEFFREY TODD WAGNER PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GATEWAY DRIVE
WADING RIVER NY
11792
US

IV. Provider business mailing address

1 GATEWAY DRIVE
WADING RIVER NY
11792
US

V. Phone/Fax

Practice location:
  • Phone: 631-929-9200
  • Fax: 631-929-9201
Mailing address:
  • Phone: 631-929-9200
  • Fax: 631-929-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number023281
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number023281
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: