Provider Demographics
NPI:1902909153
Name:WAGNER, JEAN EVELYN VOGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:EVELYN VOGEL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEAN
Other - Middle Name:EVELYN
Other - Last Name:VOGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1230 GEORGE E CHANCE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232
Mailing Address - Country:US
Mailing Address - Phone:618-345-5437
Mailing Address - Fax:618-344-9246
Practice Address - Street 1:1230 GEORGE E CHANCE PARKWAY
Practice Address - Street 2:
Practice Address - City:CASEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62232
Practice Address - Country:US
Practice Address - Phone:618-345-5437
Practice Address - Fax:618-344-9246
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105844208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105844Medicaid