Provider Demographics
NPI:1669274395
Name:WAGNER, MARCUS ALAN (DPT)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:ALAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:836 N ROLLING RD
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4136
Practice Address - Country:US
Practice Address - Phone:443-514-0560
Practice Address - Fax:410-788-8590
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-25
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT021620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist