Provider Demographics
NPI:1699909432
Name:WAGNER, ANJA (MD)
Entity type:Individual
Prefix:DR
First Name:ANJA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 MAIN ST
Mailing Address - Street 2:STE 216
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5301
Mailing Address - Country:US
Mailing Address - Phone:203-696-3495
Mailing Address - Fax:203-581-6509
Practice Address - Street 1:2979 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4284
Practice Address - Country:US
Practice Address - Phone:203-683-5100
Practice Address - Fax:203-683-5140
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050151207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease