Provider Demographics
NPI:1992781975
Name:WAGENBERG, HOWARD (DPM)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:
Last Name:WAGENBERG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HERON COVE DR
Mailing Address - Street 2:
Mailing Address - City:MERRIMACK
Mailing Address - State:NH
Mailing Address - Zip Code:03054-4866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 HERON COVE DR
Practice Address - Street 2:
Practice Address - City:MERRIMACK
Practice Address - State:NH
Practice Address - Zip Code:03054-4866
Practice Address - Country:US
Practice Address - Phone:603-880-9177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH157213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30364154Medicaid
NHDC3586OtherPALMETTO GBA RAILROAD MEDICARE
NH0308252Y0NH02OtherANTHEM BLUE CROSS BLUE SHIELD
NHT25729Medicare UPIN
NH0308252Y0NH02OtherANTHEM BLUE CROSS BLUE SHIELD
NH30364154Medicaid