Provider Demographics
NPI:1841504503
Name:WAGNER, MATTHEW PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PHILLIP
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PKWY STE 235
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3260
Mailing Address - Country:US
Mailing Address - Phone:410-266-2770
Mailing Address - Fax:410-841-6251
Practice Address - Street 1:2002 MEDICAL PKWY STE 235
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3260
Practice Address - Country:US
Practice Address - Phone:410-266-2770
Practice Address - Fax:410-841-6251
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD795522085R0202X
VA01012598442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty