Healthcare Provider Details

I. General information

NPI: 1922071646
Provider Name (Legal Business Name): BARRY ALAN WAGNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12229 VENTURA BLVD
STUDIO CITY CA
91604-2576
US

IV. Provider business mailing address

5343 FREMANTLE LN
CALABASAS CA
91302-3113
US

V. Phone/Fax

Practice location:
  • Phone: 818-880-2020
  • Fax: 818-880-1888
Mailing address:
  • Phone: 818-880-2020
  • Fax: 818-880-1888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5104TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: