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NPI Code Detail

MEDICARE: ELLIOTT JAY WAGNER M.D.

MEDICARE: ELLIOTT JAY 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
12085R0202XDiagnostic Radiology Physician238657-1NY
22085R0202XDiagnostic Radiology Physician036120986IL
32085R0202XDiagnostic Radiology PhysicianMD2008-0777NM
42085R0202XDiagnostic Radiology Physician25MA08122100NJ
52085R0202XDiagnostic Radiology PhysicianG49698CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
100G496980OTHERCABLUE SHIELD
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1558312579
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELLIOTT JAY WAGNER M.D.
Provider Business Mailing Address
First Line : 200 EAST 66TH ST
Second Line : C904
City : NEW YORK
State : NY
Zip : 10065-9175
Country : US
Telephone Number : 888-886-5238
Fax Number : 888-886-9330
Provider Business Practice Location Address
First Line : 8750 WILSHIRE BLVD STE 100
Second Line :
City : BEVERLY HILLS
State : CA
Zip : 90211-2708
Country : US
Telephone Number : 310-689-3100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/15/2006
Last Update Date : 07/29/2025

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