1336121870 NPI number — JOHN F WAGNER MD

Table of content: JOHN F WAGNER MD (NPI 1336121870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336121870 NPI number — JOHN F WAGNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
JOHN
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336121870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7120 CLEARVISTA DR
Provider Second Line Business Practice Location Address:
SUITE 4000
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46256-1774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-577-7444
Provider Business Practice Location Address Fax Number:
317-577-7433
Provider Enumeration Date:
11/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  01039812A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100370080 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000647926 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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