| Doctor Name: | DR. JOHN OTTO WAGNER |
| NPI Number: | 1942316385 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | |
| Business Practice Address: | 1950 Stanley Rd Bldg 2376 San Antonio Military Entrance Processing Station Fort Sam Houston, TX - 782347547 |
| Business Phone Number: | 2103232209 |
| Business Fax Number: | 8883236008 |
| Mailing Address: | 626 Crestway Dr, SAN ANTONIO |
| State: | TX |
| Postal Code: | 782392152 |
| Phone Number: | 2103232209 |
| Fax Number: | 8883236008 |
| NPI Enumeration Date: | 08/21/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |