MEDICARE: DR. TODD L WAGNER D.O., M.P.H.

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	2083P0901X	Public Health & General Preventive Medicine Physician	20A8267	CA

General Provider Information

NPI Number	:	1629067517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TODD L WAGNER D.O., M.P.H.

Provider Business Mailing Address
First Line	:	2773 PLEASANT ACRES DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-7326
Country	:	US
Telephone Number	:	757-953-6552
Fax Number	:

Provider Business Practice Location Address
First Line	:	1887 POWHATAN ST.
Second Line	:	NAVY ENVIRONMENTAL AND PREVENTIVE MEDICINE UNIT 2
City	:	NORFOLK
State	:	VA
Zip	:	23511
Country	:	US
Telephone Number	:	757-935-6552
Fax Number	:

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

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	07/21/2008

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