Individual
MICHELLE I CERVIN -WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
320 S DR MARTIN LUTHER KING JR BLVD STE 300, SOUTH BEND, IN 46601-2358
(574) 406-6376
(574) 406-6377
Mailing address
14504 DOUGLAS RD, MISHAWAKA, IN 46545-1709
(574) 344-0479
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
02001685
IN
207Q00000X
Family Medicine Physician
5101011099
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1891711362
—
MI
Enumeration date
07/15/2006
Last updated
02/24/2025
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