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NPI Code Detail

MEDICARE: FREDRICK CHARLES WAGNER MD

MEDICARE: FREDRICK CHARLES 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
12085R0001XRadiation Oncology PhysicianMD09972OR

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 : 1609869635
Entity Type Code : Individual
Provider Name (Legal Business Name) : FREDRICK CHARLES WAGNER MD
Provider Business Mailing Address
First Line : 975 SE SANDY BLVD
Second Line : SUITE 200
City : PORTLAND
State : OR
Zip : 97214-1308
Country : US
Telephone Number : 503-963-2846
Fax Number : 503-963-9505
Provider Business Practice Location Address
First Line : 9205 SW BARNES RD
Second Line :
City : PORTLAND
State : OR
Zip : 97225-6603
Country : US
Telephone Number : 503-216-2195
Fax Number : 503-216-2196
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/24/2005
Last Update Date : 07/09/2007

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Directions to “ FREDRICK CHARLES WAGNER MD” Practice Location

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