Basic Information
| Provider Information | |||||||||
| NPI: | 1407815038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | KARLA | ||||||||
| MiddleName: | MONTGOMERY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MONTGOMERY-WAGNER | ||||||||
| OtherFirstName: | KARLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2111 LAUREL BUSH RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105693300 | ||||||||
| FaxNumber: | 4105152027 | ||||||||
| Practice Location | |||||||||
| Address1: | 2111 LAUREL BUSH RD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105693300 | ||||||||
| FaxNumber: | 4105152027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | D0045592 | MD | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.