MEDICARE: HAROLD G WAGNER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	H6679	TX
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	H6679	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00207035	OTHER	TX	RAILROAD MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	008PH	OTHER	TX	BCBS PIN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114015138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAROLD G WAGNER D.O.

Provider Business Mailing Address
First Line	:	7441 MARVIN D LOVE FWY
Second Line	:	STE 300
City	:	DALLAS
State	:	TX
Zip	:	75237-3490
Country	:	US
Telephone Number	:	972-572-1998
Fax Number	:	972-572-4842

Provider Business Practice Location Address
First Line	:	7441 MARVIN D LOVE FWY
Second Line	:	STE 300
City	:	DALLAS
State	:	TX
Zip	:	75237-3490
Country	:	US
Telephone Number	:	972-572-1998
Fax Number	:	972-572-4842

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	03/03/2010

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Directions to “ HAROLD G WAGNER D.O.” Practice Location

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