DR. MATTHEW ROBERT WAGNER MD NPI 1114198751

NPI Information

  • NPI: 1114198751
  • Provider Name: DR. MATTHEW ROBERT WAGNER, MD
  • Classification: Orthopaedic Surgery - 207XP3100X
  • Specialization: Pediatric Orthopaedic Surgery
  • Entity Type: Individual
  • PECOS Registration: Yes
  • Address: 1500 ROUTE 112 BLDG 2C
    PORT JEFFERSON STATION, NY
    ZIP 11776
  • Phone: (631) 371-8034

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NPI Details

DR. Matthew Robert Wagner, MD is a pediatric orthopaedic surgery orthopaedic surgery in Port Jefferson Station, NY. The provider is an orthopedic surgeon who has additional training and experience in diagnosing, treating and managing musculoskeletal problems in infants, children and adolescents. These may include limb and spine deformities (such as club foot, scoliosis); gait abnormalities (limping); bone and joint infections; broken bones. DR. Matthew Robert Wagner, MD NPI is 1114198751. The provider is registered as an individual entity type.

The NPPES NPI record indicates the provider is a male.

The provider's business location address is:

1500 ROUTE 112 BLDG 2C
PORT JEFFERSON STATION, NY
ZIP 11776-055
Phone: (631) 371-8034
Fax: (631) 828-7899

The NPI 1114198751 is registered in the Medicare Provider, Enrollment, Chain and Ownership System (PECOS). The provider is legally eligible to order and refer Part B (Clinical Laboratory and Imaging), Durable Medical Equipment, Part A Home Health Agency (HHA), Power Mobility Devices.

The enumeration date for this NPI number is 3/21/2008 and was last updated on 11/5/2019.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1207XP3100XOrthopaedic SurgeryPediatric Orthopaedic SurgeryME103612FLORIDANo
2207XP3100XOrthopaedic SurgeryPediatric Orthopaedic Surgery251727NEW YORKYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1120130521000407OTHERNEW YORKMEDICARE

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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