Healthcare Provider Details

I. General information

NPI: 1629067517
Provider Name (Legal Business Name): TODD L WAGNER D.O., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 POWHATAN ST. NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT 2
NORFOLK VA
23511
US

IV. Provider business mailing address

2773 PLEASANT ACRES DR
VIRGINIA BEACH VA
23453-7326
US

V. Phone/Fax

Practice location:
  • Phone: 757-935-6552
  • Fax:
Mailing address:
  • Phone: 757-953-6552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number20A8267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: