Provider Demographics
NPI:1306899539
Name:WAGNER, TIMOTHY R (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TIMOTHY
Other - Middle Name:R
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:330 MERCY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2332
Mailing Address - Country:US
Mailing Address - Phone:843-374-6431
Mailing Address - Fax:
Practice Address - Street 1:330 MERCY STREET
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560
Practice Address - Country:US
Practice Address - Phone:843-374-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29577207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64295777Medicaid
KY1559101Medicare ID - Type Unspecified
SC8305Medicare PIN
KYB91527Medicare UPIN
KY64295777Medicaid