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General NPI Number Information
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NPI Number | 1821640145
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Entity Type | Organization
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Legal Business Name | SDPM MEDICAL GROUP, INCORPORATED
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Dates
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Enumeration Date | 07/16/2019
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Last Update Date | 01/07/2020
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Provider Practice Location Address
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Address Line | 9850 GENESEE AVE STE 820
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City | LA JOLLA
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State | CA
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Zip | 92037-1219
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Country | US
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Telephone | 858-454-5442
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Fax | 858-431-4633
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Provider Business Mailing Address
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Address Line | PO BOX 221048
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City | SAN DIEGO
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State | CA
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Zip | 92192-1048
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Country | US
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Telephone | 858-395-0309
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Fax | 858-452-9027
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT LEE WAGNER JR.
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Credential | MD
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Telephone | 858-454-5442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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