Provider Demographics
NPI:1265623268
Name:WAGNON, JON ANTHONY (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:ANTHONY
Last Name:WAGNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1368 DADRIAN PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1685
Mailing Address - Country:US
Mailing Address - Phone:618-433-9701
Mailing Address - Fax:618-433-9706
Practice Address - Street 1:1368 DADRIAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1685
Practice Address - Country:US
Practice Address - Phone:618-433-9701
Practice Address - Fax:618-433-9706
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006033803207Q00000X
IL036120316207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120316Medicaid