=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245393529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN HARVEY WAGONER M.D., PH.D., MBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 12/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 OLD SOLOMONS ISLAND ROAD BAYSHORE COUNSELING AND PSYCHOLOGICAL SERVICES, LLC
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-266-9747
-----------------------------------------------------
Fax | 410-266-9749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 133 OLD SOLOMONS ISLAND ROAD
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-266-9747
-----------------------------------------------------
Fax | 410-266-9749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 03283
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | D48079
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------