Provider Demographics
NPI:1396908265
Name:WAGNER, KATHERINE MARY (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:216-475-8844
Mailing Address - Fax:216-475-3816
Practice Address - Street 1:13201 GRANGER RD STE 2
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-1979
Practice Address - Country:US
Practice Address - Phone:216-475-8844
Practice Address - Fax:216-475-3816
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35-096862208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3149168Medicaid
OH3149168Medicaid