Provider Demographics
NPI:1639127152
Name:WAGNER, AUDREY SUSAN (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:SUSAN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5200
Practice Address - Fax:617-972-5512
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ17306OtherBLUE CROSS
MA0015296OtherNEIGHBORHOOD HEALTH
MAV467OtherHARVARD PILGRIM
MA076506OtherTUFTS
MA3196241Medicaid
MAJ17306OtherBLUE CROSS
MAF48587Medicare UPIN