Provider Demographics
NPI:1619973179
Name:WAGNER, RICHARD ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 W COLUMBIA ST
Mailing Address - Street 2:STE 450
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-5610
Mailing Address - Country:US
Mailing Address - Phone:812-425-1596
Mailing Address - Fax:812-425-0799
Practice Address - Street 1:350 W COLUMBIA ST
Practice Address - Street 2:STE 450
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-5610
Practice Address - Country:US
Practice Address - Phone:812-425-1596
Practice Address - Fax:812-425-0799
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100242040AMedicaid
IN791011699Medicare PIN
IN100242040AMedicaid
IN837640Medicare PIN