Healthcare Provider Details

I. General information

NPI: 1700821709
Provider Name (Legal Business Name): MARK S WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 CABRILLO PARK DR SUITE 120
SANTA ANA CA
92701-5016
US

IV. Provider business mailing address

PO BOX 94026
PASADENA CA
91109-4026
US

V. Phone/Fax

Practice location:
  • Phone: 714-558-8038
  • Fax: 714-558-6033
Mailing address:
  • Phone: 714-558-8038
  • Fax: 714-558-6033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberG42267
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG42267
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG42267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: