Provider Demographics
NPI:1083655179
Name:WAGNER, SCOTT DAVID (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 EXECUTIVE DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7445
Mailing Address - Country:US
Mailing Address - Phone:919-878-8596
Mailing Address - Fax:919-878-0744
Practice Address - Street 1:3320 EXECUTIVE DR
Practice Address - Street 2:SUITE 214
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7445
Practice Address - Country:US
Practice Address - Phone:919-878-8596
Practice Address - Fax:919-878-0744
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH20149Medicare UPIN