Healthcare Provider Details

I. General information

NPI: 1134488687
Provider Name (Legal Business Name): JOHN WAGDY FAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 BROADCASTING RD STE 100
WYOMISSING PA
19610-3221
US

IV. Provider business mailing address

1220 BROADCASTING RD STE 100
WYOMISSING PA
19610-3221
US

V. Phone/Fax

Practice location:
  • Phone: 484-628-5673
  • Fax:
Mailing address:
  • Phone: 484-628-5673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD460652
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: