Provider Demographics
NPI:1598854184
Name:WAGNER, STEVENTON SCOTT (DPM)
Entity type:Individual
Prefix:DR
First Name:STEVENTON
Middle Name:SCOTT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2501
Mailing Address - Country:US
Mailing Address - Phone:614-488-9478
Mailing Address - Fax:614-488-4836
Practice Address - Street 1:1208 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2501
Practice Address - Country:US
Practice Address - Phone:614-488-9478
Practice Address - Fax:614-488-4836
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002797213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0992707Medicaid
OH480020534OtherRAILROAD MEDICARE
OH0766892Medicare PIN