Provider Demographics
NPI:1053372987
Name:WAGNER, CHRISTIAN T (MD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:T
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:ATTN PHYSICIAN SERVICES WOT 12TH FLOOR
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-853-2716
Practice Address - Fax:508-856-9025
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2026412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3204235OtherMEDICAID WELFARE
44949OtherFALLON COMMUNITY HEALTH P
784219OtherMVP HEALTH CARE
A30514OtherMEDICARE B
7370306OtherAETNA US HEALTHCARE
3204235OtherHEALTHY START
MA3204235Medicaid
7200046OtherCIGNA HEALTH PLAN
AA5533OtherHARVARD PILGRIM HEALTHCAR
J21993OtherBLUE SHIELD INDEMNITY
1818742OtherFIRST HEALTH
J21993OtherBLUE CARE ELECT
J21993OtherBLUE SHIELD HMO BLUE
AA5533OtherHARVARD PILGRIM HEALTHCAR
MA3204235Medicaid