Healthcare Provider Details

I. General information

NPI: 1962403774
Provider Name (Legal Business Name): PETER JOHN WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

IV. Provider business mailing address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

V. Phone/Fax

Practice location:
  • Phone: 760-837-8767
  • Fax: 760-837-8806
Mailing address:
  • Phone: 760-837-8767
  • Fax: 760-837-8806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberC130554
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number36158
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36158
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC130554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: