Provider Demographics
NPI:1891711362
Name:CERVIN -WAGNER, MICHELLE I (DO)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:I
Last Name:CERVIN -WAGNER
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:I
Other - Last Name:CERVIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14504 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1709
Mailing Address - Country:US
Mailing Address - Phone:574-344-0479
Mailing Address - Fax:
Practice Address - Street 1:320 S DR MARTIN LUTHER KING JR BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-2358
Practice Address - Country:US
Practice Address - Phone:574-406-6376
Practice Address - Fax:574-406-6377
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011099207Q00000X
IN02001685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1891711362Medicaid