Provider Demographics
NPI:1558312579
Name:WAGNER, ELLIOTT JAY (MD)
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:JAY
Last Name:WAGNER
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 1:200 EAST 66TH ST
Mailing Address - Street 2:C904
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-9175
Mailing Address - Country:US
Mailing Address - Phone:888-886-5238
Mailing Address - Fax:888-886-9330
Practice Address - Street 1:8750 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2708
Practice Address - Country:US
Practice Address - Phone:310-689-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238657-12085R0202X
IL0361209862085R0202X
NMMD2008-07772085R0202X
NJ25MA081221002085R0202X
CAG496982085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G496980OtherBLUE SHIELD
NY02917751Medicaid
CA00G496980Medicaid
A51438Medicare UPIN
NY02917751Medicaid
CA300016066Medicare PIN