Healthcare Provider Details

I. General information

NPI: 1740074699
Provider Name (Legal Business Name): MARK BRIAN WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MEDICAL CENTER BLVD
WEBSTER TX
77598-4220
US

IV. Provider business mailing address

5540 OSO PKWY APT 14
CORPUS CHRISTI TX
78413-6226
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-2511
  • Fax:
Mailing address:
  • Phone: 361-658-9684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: