MEDICARE: JOHN DAVID WAGNER MD

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	2080P0202X	Pediatric Cardiology Physician	91568	GA

General Provider Information

NPI Number	:	1144789298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN DAVID WAGNER MD

Provider Business Mailing Address
First Line	:	2835 BRANDYWINE RD STE 400
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-5540
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2970 BRANDYWINE RD STE 125
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-5528
Country	:	US
Telephone Number	:	713-790-9401
Fax Number	:

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

Provider Enumeration Date	:	03/18/2019
Last Update Date	:	07/17/2025

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