Healthcare Provider Details

I. General information

NPI: 1336360288
Provider Name (Legal Business Name): BARRY A. WAGNER OD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12229 VENTURA BLVD
STUDIO CITY CA
91604-2576
US

IV. Provider business mailing address

12229 VENTURA BLVD
STUDIO CITY CA
91604-2576
US

V. Phone/Fax

Practice location:
  • Phone: 818-623-8900
  • Fax: 818-623-0978
Mailing address:
  • Phone: 818-623-8900
  • Fax: 818-623-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: BARRY ALAN WAGNER
Title or Position: OPTOMETRIST
Credential: OD
Phone: 818-985-2321