Provider Demographics
NPI:1326188293
Name:WAGNER, JAMES GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GEORGE
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 315 GARDEN HILLS PLAZA
Mailing Address - Street 2:1353 RD. 19
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-0096
Mailing Address - Country:US
Mailing Address - Phone:787-627-2788
Mailing Address - Fax:787-653-2370
Practice Address - Street 1:8000 AVE. J.T. PINERO
Practice Address - Street 2:PLAZA CAYEY, OF. 204
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-627-2788
Practice Address - Fax:787-653-2370
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12634207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0020398Medicare ID - Type UnspecifiedPROVIDER NUMBER