Provider Demographics
NPI:1285614511
Name:WAGONER, DON J (MD)
Entity type:Individual
Prefix:DR
First Name:DON
Middle Name:J
Last Name:WAGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:605 E. 7TH ST.
Mailing Address - City:BURLINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46915-0038
Mailing Address - Country:US
Mailing Address - Phone:765-566-3351
Mailing Address - Fax:765-566-2250
Practice Address - Street 1:605 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IN
Practice Address - Zip Code:46915-9441
Practice Address - Country:US
Practice Address - Phone:765-566-3351
Practice Address - Fax:765-566-2250
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01019897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100135360BMedicaid
IN100135360BMedicaid
IN219510DMedicare ID - Type UnspecifiedINDIVIDUAL MEDICARE