Healthcare Provider Details

I. General information

NPI: 1841458023
Provider Name (Legal Business Name): KLAUS WOLFGANG WAGNER MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2008
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR VA HEMATOLOGY/ONCOLOGY
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR HEMATOLOGY/ONCOLOGY
SAN DIEGO CA
92161-0002
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone: 858-552-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberA119744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: