Individual
JACK WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1850 GATEWAY DR, SYCAMORE, IL 60178-3192
(815) 758-8671
(815) 758-5610
Mailing address
1850 GATEWAY DR, SYCAMORE, IL 60178-3192
(815) 758-8671
(815) 758-5610
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
036-100314
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036100314
—
IL
01
—
048118
HEALTH ALLIANCE
IL
Enumeration date
08/13/2006
Last updated
06/11/2012
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