1902026206 NPI number — DR. JAMES P WAGNER OD

Table of content: DR. JAMES P WAGNER OD (NPI 1902026206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902026206 NPI number — DR. JAMES P WAGNER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGNER
Provider First Name:
JAMES
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1902026206
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 S 76TH ST
Provider Second Line Business Mailing Address:
STE 690
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53129-1102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-855-0469
Provider Business Mailing Address Fax Number:
414-855-0492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 S 76TH ST
Provider Second Line Business Practice Location Address:
STE 690
Provider Business Practice Location Address City Name:
GREENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53129-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-855-0469
Provider Business Practice Location Address Fax Number:
414-855-0492
Provider Enumeration Date:
04/27/2007

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: 152W00000X , with the licence number:  2645-035 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 810571047 . This is a "TAX ID" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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