Provider Demographics
NPI:1528108867
Name:WAGEMAN, DAVID DALE (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DALE
Last Name:WAGEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 MCMANUS DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1551
Mailing Address - Country:US
Mailing Address - Phone:734-673-0245
Mailing Address - Fax:
Practice Address - Street 1:1224 8TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1599
Practice Address - Country:US
Practice Address - Phone:208-436-0481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015277207P00000X, 207R00000X
IDO-0753207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101015277OtherLICENSE