=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902260714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK S WAGNER MD, A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2016
-----------------------------------------------------
Last Update Date | 01/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 CABRILLO PARK DR SUITE 120
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-5016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-558-8038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 261 W HOWARD ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91103-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-218-3892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO / PRESIDENT
-----------------------------------------------------
Name | DR. MARK S WAGNER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 714-558-8038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 95003992
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------