Basic Information
| Provider Information | |||||||||
| NPI: | 1063469419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGENKNECHT | ||||||||
| FirstName: | WALTER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013020910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137728500 | ||||||||
| FaxNumber: | 4137728900 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053017601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006553603 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0420010063 | VT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1004285 | 05 | VT | MEDICAID |