Individual
DR. MATTHEW ROBERT WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 ROUTE 112 BLDG 2C, PORT JEFFERSON STATION, NY 11776-8055
(631) 371-8034
(631) 828-7899
Mailing address
1500 ROUTE 112 BLDG 2C, PORT JEFFERSON STATION, NY 11776-8055
(631) 371-8034
(631) 828-7899
Taxonomy
Speciality
Code
Description
License number
State
207XP3100X
Pediatric Orthopaedic Surgery Physician
Primary
251727
NY
207XP3100X
Pediatric Orthopaedic Surgery Physician
ME103612
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
120130521000407
MEDICARE
NY
Enumeration date
03/21/2008
Last updated
11/05/2019
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