Provider Demographics
NPI:1982810289
Name:VAAGENES, PETTER ANDRE (DO)
Entity type:Individual
Prefix:DR
First Name:PETTER
Middle Name:ANDRE
Last Name:VAAGENES
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 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-4144
Mailing Address - Fax:220-564-7153
Practice Address - Street 1:1320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-4144
Practice Address - Fax:220-564-7153
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009309207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2933151Medicaid
OHH192422Medicare PIN
OH4248014Medicare PIN