Healthcare Provider Details

I. General information

NPI: 1407896616
Provider Name (Legal Business Name): ELISABETH A WAGNER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 8TH AVENUE SUITE 435
FORT WORTH TX
76104-4144
US

IV. Provider business mailing address

P. O. BOX 961205
FORT WORTH TX
76161-1205
US

V. Phone/Fax

Practice location:
  • Phone: 817-923-0088
  • Fax: 817-924-5144
Mailing address:
  • Phone: 817-740-8400
  • Fax: 817-924-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM8411
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: