Provider Demographics
NPI:1518917830
Name:WAGGENER, RICHARD G (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:WAGGENER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CAMPUS DR STE 10
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-8812
Mailing Address - Country:US
Mailing Address - Phone:763-559-2171
Mailing Address - Fax:
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-398-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2136905Medicaid
KY64325491Medicaid
KY1054560Medicaid
IN200114300Medicaid
GA274540900AMedicaid
KY000000062498OtherANTHEM BLUE FACET
NY01773615Medicaid
MI4817171Medicaid
CAXPY200541Medicaid
TX060794701Medicaid
FL909773200Medicaid