Healthcare Provider Details

I. General information

NPI: 1235656323
Provider Name (Legal Business Name): GLENN NORMAN WAGNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5570 OVERLAND AVE STE 101
SAN DIEGO CA
92123-1215
US

IV. Provider business mailing address

5570 OVERLAND AVE STE 101
SAN DIEGO CA
92123-1215
US

V. Phone/Fax

Practice location:
  • Phone: 858-694-2899
  • Fax: 858-694-2514
Mailing address:
  • Phone: 858-694-2899
  • Fax: 858-694-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number20A4111
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: