MEDICARE: DR. ROBERT D WAGNER M.D.

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	208000000X	Pediatrics Physician	MD00020537	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285661983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT D WAGNER M.D.

Provider Business Mailing Address
First Line	:	275 SE CABOT DR STE B102
Second Line	:
City	:	OAK HARBOR
State	:	WA
Zip	:	98277-3740
Country	:	US
Telephone Number	:	360-675-5555
Fax Number	:	360-675-0275

Provider Business Practice Location Address
First Line	:	1690 LAYTON RD
Second Line	:
City	:	FREELAND
State	:	WA
Zip	:	98249-9456
Country	:	US
Telephone Number	:	360-331-1314
Fax Number	:	360-331-9703

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

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	05/29/2019

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