Provider Demographics
NPI:1538392659
Name:WAGLE, BINOD (MD)
Entity type:Individual
Prefix:
First Name:BINOD
Middle Name:
Last Name:WAGLE
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 LILLY RD NE STE 210
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-413-8550
Practice Address - Fax:360-413-8827
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD615029512084N0400X
VA0116022839390200000X
MO20140076712084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program