Provider Demographics
NPI:1215342423
Name:WAGNER, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 STRAWBERRY HILL CT STE 41042
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2778
Mailing Address - Country:US
Mailing Address - Phone:203-348-5355
Mailing Address - Fax:203-348-4082
Practice Address - Street 1:32 STRAWBERRY HILL CT STE 41042
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2778
Practice Address - Country:US
Practice Address - Phone:203-348-5355
Practice Address - Fax:203-348-4082
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT67480207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program