Provider Demographics
NPI:1316063993
Name:JOHN ALLEN VAN WAGONER, MD, PA
Entity type:Organization
Organization Name:JOHN ALLEN VAN WAGONER, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:VAN WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:972-398-3500
Mailing Address - Street 1:6101 WINDCOM CT
Mailing Address - Street 2:SUITE #400
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7817
Mailing Address - Country:US
Mailing Address - Phone:972-398-3500
Mailing Address - Fax:972-398-3512
Practice Address - Street 1:6101 WINDCOM CT
Practice Address - Street 2:SUITE #400
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7817
Practice Address - Country:US
Practice Address - Phone:972-398-3500
Practice Address - Fax:972-398-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8854174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1053389502OtherDR JOHN VANWAGONER NPI
TX142171101Medicaid
OK200032370AMedicaid
TX1053389502OtherDR JOHN VANWAGONER NPI
TX142171101Medicaid
TX1053389502OtherDR JOHN VANWAGONER NPI