Healthcare Provider Details

I. General information

NPI: 1780758003
Provider Name (Legal Business Name): KYLE L WAGAMON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 E MARKET ST
WARREN OH
44483-6204
US

IV. Provider business mailing address

19301 CYCLONE DR
CLEVELAND OH
44135-1731
US

V. Phone/Fax

Practice location:
  • Phone: 330-393-4000
  • Fax: 330-392-5870
Mailing address:
  • Phone: 330-393-4000
  • Fax: 330-392-5870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35083746
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number35083746
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: