Provider Demographics
NPI:1528051000
Name:WAGAR, DAVID B (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:WAGAR
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:PO BOX 2007
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4507
Mailing Address - Country:US
Mailing Address - Phone:315-362-5285
Mailing Address - Fax:518-563-0707
Practice Address - Street 1:16 DEGRANDPRE WAY
Practice Address - Street 2:SUITE 600
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-563-0490
Practice Address - Fax:518-563-0707
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1953942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019620800002Medicaid
PA0019620800005Medicaid
PAP00013111OtherRAILROAD MEDICARE
PA0019620800011Medicaid
PA0019620800001Medicaid
PA070108PQLMedicare PIN
PA070108YGLTMedicare PIN
PA070108EF4Medicare PIN
PAF90161Medicare UPIN
PA0019620800011Medicaid
PA0019620800005Medicaid
PA070108FJDMedicare PIN