Provider Demographics
NPI:1487989190
Name:WAGMAN, GABRIEL MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:MICHAEL
Last Name:WAGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7921
Mailing Address - Country:US
Mailing Address - Phone:631-666-2290
Mailing Address - Fax:631-647-5299
Practice Address - Street 1:1916 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7921
Practice Address - Country:US
Practice Address - Phone:631-666-2290
Practice Address - Fax:631-647-5299
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY255002207RA0002X, 207RH0005X, 207UN0902X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension Specialist
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03166589Medicaid
NY03166589Medicaid