Healthcare Provider Details

I. General information

NPI: 1689029456
Provider Name (Legal Business Name): SARITA WAGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E. MARSHALL ST. BOX 980264
RICHMOND VA
23298
US

IV. Provider business mailing address

1250 E. MARSHALL ST. BOX 980264
RICHMOND VA
23298
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9955
  • Fax: 804-828-5775
Mailing address:
  • Phone: 804-828-9955
  • Fax: 804-828-5775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD92412
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: