MEDICARE: BRUCE WAGNER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	6376	CA

General Provider Information

NPI Number	:	1053434035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE WAGNER OD

Provider Business Mailing Address
First Line	:	24040 CAMINO DEL AVION STE E
Second Line	:
City	:	MONARCH BEACH
State	:	CA
Zip	:	92629-4005
Country	:	US
Telephone Number	:	949-443-9110
Fax Number	:

Provider Business Practice Location Address
First Line	:	24040 CAMINO DEL AVION STE E
Second Line	:
City	:	MONARCH BEACH
State	:	CA
Zip	:	92629-4005
Country	:	US
Telephone Number	:	949-443-9110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	07/08/2007

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