Provider Demographics
NPI:1487743969
Name:WAGNER, DONNA RM (MD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:RM
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5749
Mailing Address - Country:US
Mailing Address - Phone:361-573-9181
Mailing Address - Fax:
Practice Address - Street 1:2701 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5749
Practice Address - Country:US
Practice Address - Phone:361-573-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0338207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742710179A011OtherCHAMPUS
TXMDJ0338TXOtherWORKERS COMPENSATION
TN123558203Medicaid
TX742710179A011OtherCHAMPUS
TXF76227Medicare UPIN
TX87W150Medicare PIN