Individual
RUSSELL WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 S MAIN ST, FORT WORTH, TX 76104-4917
(817) 702-7144
Mailing address
PO BOX 99335, FORT WORTH, TX 76199-0335
(817) 735-2900
(817) 735-2902
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
H4772
TX
207XS0114X
Adult Reconstructive Orthopaedic Surgery Physician
H4772
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
123495705
—
TX
01
—
8U1280
BCBS
TX
01
—
P00249664
RAILROAD MEDICARE PIN
TX
Enumeration date
06/15/2006
Last updated
12/18/2023
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