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NPI Code Detail

MEDICARE: CHARLES JOHN WAGNER MD

MEDICARE: CHARLES JOHN 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
1207K00000XAllergy & Immunology PhysicianOR14081OR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1366540742
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES JOHN WAGNER MD
Provider Business Mailing Address
First Line : 1793 13TH ST SE
Second Line :
City : SALEM
State : OR
Zip : 97302-2541
Country : US
Telephone Number : 503-362-8385
Fax Number : 503-362-8435
Provider Business Practice Location Address
First Line : 1793 13TH ST SE
Second Line :
City : SALEM
State : OR
Zip : 97302-2541
Country : US
Telephone Number : 503-362-8385
Fax Number : 503-362-8435
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/20/2006
Last Update Date : 07/05/2016

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Directions to “ CHARLES JOHN WAGNER MD” Practice Location

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