Provider Demographics
NPI:1871582130
Name:WAGONER, CHAD ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:ERIC
Last Name:WAGONER
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 1:1615 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-3020
Mailing Address - Country:US
Mailing Address - Phone:417-359-8803
Mailing Address - Fax:417-359-8454
Practice Address - Street 1:1615 HAZEL ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-3020
Practice Address - Country:US
Practice Address - Phone:417-359-8803
Practice Address - Fax:417-359-8454
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine