Healthcare Provider Details

I. General information

NPI: 1568924231
Provider Name (Legal Business Name): BENJAMIN PAUL WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4256 HACIENDA DR STE 100
PLEASANTON CA
94588-8595
US

IV. Provider business mailing address

4256 HACIENDA DR STE 100
PLEASANTON CA
94588-8595
US

V. Phone/Fax

Practice location:
  • Phone: 925-264-6510
  • Fax: 925-263-0251
Mailing address:
  • Phone: 925-264-6510
  • Fax: 925-263-0251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA208292
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61339518
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: