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General NPI Number Information
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NPI Number | 1528108867
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Entity Type | Individual
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Provider Name | DAVID DALE WAGEMAN DO
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Gender | Male
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 06/06/2025
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Provider Practice Location Address
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Address Line | 1224 8TH ST
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City | RUPERT
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State | ID
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Zip | 83350-1599
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Country | US
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Telephone | 208-436-0481
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Fax |
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Provider Business Mailing Address
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Address Line | 1640 MCMANUS DR
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City | TROY
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State | MI
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Zip | 48084-1551
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Country | US
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Telephone | 734-673-0245
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Fax |
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 5101015277
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 5101015277
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | O-0753
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License Number State | ID
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