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General NPI Number Information
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NPI Number | 1114198751
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Entity Type | Individual
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Provider Name | MATTHEW ROBERT WAGNER MD
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Gender | Male
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Dates
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Enumeration Date | 03/21/2008
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Last Update Date | 11/05/2019
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Provider Practice Location Address
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Address Line | 1500 ROUTE 112 BLDG 2C
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8055
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Country | US
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Telephone | 631-371-8034
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Fax | 631-828-7899
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Provider Business Mailing Address
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Address Line | 1500 ROUTE 112 BLDG 2C
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-8055
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Country | US
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Telephone | 631-371-8034
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Fax | 631-828-7899
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XP3100X
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Taxonomy Name | Pediatric Orthopaedic Surgery Physician
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License Number | ME103612
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207XP3100X
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Taxonomy Name | Pediatric Orthopaedic Surgery Physician
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License Number | 251727
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License Number State | NY
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