Healthcare Provider Details

I. General information

NPI: 1124161872
Provider Name (Legal Business Name): LLOYD DAVID WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 24TH ST
SANTA MONICA CA
90402-2515
US

IV. Provider business mailing address

223 24TH ST
SANTA MONICA CA
90402-2515
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 888-886-5238
  • Fax: 888-886-9330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA09610500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number164449
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG70226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: