Provider Demographics
NPI:1144321365
Name:WAGNER, REENA (MD)
Entity type:Individual
Prefix:MRS
First Name:REENA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SQUADRON BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5210
Mailing Address - Country:US
Mailing Address - Phone:845-634-9729
Mailing Address - Fax:845-634-9018
Practice Address - Street 1:18 SQUADRON BLVD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5210
Practice Address - Country:US
Practice Address - Phone:845-634-9726
Practice Address - Fax:845-634-9018
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA643512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00619209OtherRAILROAD MCR
NJ7045107Medicaid
NJ0408529OtherGHI
NJ7045107Medicaid
NJ0408529OtherGHI
NJP00619209OtherRAILROAD MCR