Individual
THEODORE T WAGNER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3920 ST FRANCIS WAY STE 105, LAFAYETTE, IN 47905-4917
(765) 502-4000
(765) 502-4709
Mailing address
PO BOX 781076, DETROIT, MI 48278-1076
(317) 528-4800
(317) 865-1479
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
01050471A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000087512
ANTHEM BC/BS
IN
05
—
0748972
—
OH
05
—
100081380
—
IN
05
—
200245650
—
IN
05
—
2568556
—
OH
Enumeration date
02/10/2006
Last updated
03/24/2026
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