Healthcare Provider Details

I. General information

NPI: 1205367232
Provider Name (Legal Business Name): ERIC WAGREICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST CLINIC TOWER, SUITE A7D
LOS ANGELES CA
90033-1029
US

IV. Provider business mailing address

2010 ZONAL AVE # 1P10
LOS ANGELES CA
90033-1026
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA161162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: