Provider Demographics
NPI:1902124225
Name:CONNECTICUT FOOT SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:CONNECTICUT FOOT SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-653-4708
Mailing Address - Street 1:43 WOODLAND ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2363
Mailing Address - Country:US
Mailing Address - Phone:860-251-7200
Mailing Address - Fax:
Practice Address - Street 1:43 WOODLAND ST
Practice Address - Street 2:SUITE 210
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2363
Practice Address - Country:US
Practice Address - Phone:260-251-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000793213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTCT000793OtherDR. WAGNER'S STATE LICENSE
CT1093743502OtherDR. WAGNER'S NPI
CT1093743502OtherDR. WAGNER'S NPI