Provider Demographics
NPI:1194768754
Name:WAGENAAR, JAMES S (DO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:S
Last Name:WAGENAAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 CAMPBELL DR
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2301
Mailing Address - Country:US
Mailing Address - Phone:740-533-9710
Mailing Address - Fax:740-553-9712
Practice Address - Street 1:1408 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2301
Practice Address - Country:US
Practice Address - Phone:740-533-9710
Practice Address - Fax:740-533-9712
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005359207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000493481OtherANTHEM BCBS
000702618OtherMOUNTAIN STATE BCBS
OH000000210197OtherOH MEDICAID UNISON
OH310917085154OtherOH MEDICAID CARESOURCE
WV0043615000Medicaid
OH0843529Medicaid
OH310917085154OtherOH MEDICAID CARESOURCE
000702618OtherMOUNTAIN STATE BCBS