Individual
JAMES S WAGENAAR
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1408 CAMPBELL DR, IRONTON, OH 45638-2301
(740) 533-9710
(740) 533-9712
Mailing address
1408 CAMPBELL DR, IRONTON, OH 45638-2301
(740) 533-9710
(740) 553-9712
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
34005359
OH
207PE0004X
Emergency Medical Services (Emergency Medicine) Physician
34005359
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000210197
OH MEDICAID UNISON
OH
01
—
000000493481
ANTHEM BCBS
—
01
—
000702618
MOUNTAIN STATE BCBS
—
05
—
0043615000
—
WV
05
—
0843529
—
OH
01
—
310917085154
OH MEDICAID CARESOURCE
OH
Enumeration date
06/13/2006
Last updated
10/29/2020
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