Healthcare Provider Details

I. General information

NPI: 1336130087
Provider Name (Legal Business Name): MARK ANDREW WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36680 CLOVERLEAF AVE
MADERA CA
93636-8519
US

IV. Provider business mailing address

4301 NORTHSTAR WAY
MODESTO CA
95356-9262
US

V. Phone/Fax

Practice location:
  • Phone: 209-489-9347
  • Fax: 209-720-0107
Mailing address:
  • Phone: 209-342-2300
  • Fax: 209-524-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20A5259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: