Healthcare Provider Details

I. General information

NPI: 1174531388
Provider Name (Legal Business Name): PETER WILLIAM WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MCCREIGHT AVE SUITE 208
SPRINGFIELD OH
45504-1842
US

IV. Provider business mailing address

30 W MCCREIGHT AVE SUITE 208
SPRINGFIELD OH
45504-1842
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-7021
  • Fax: 937-399-0697
Mailing address:
  • Phone: 937-399-7021
  • Fax: 937-399-0697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOH35-04-2823
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: