Provider Demographics
NPI:1003836248
Name:WAGNER, WILLIS H (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIS
Middle Name:H
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8631 W 3RD ST
Mailing Address - Street 2:SUITE 615E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5901
Mailing Address - Country:US
Mailing Address - Phone:310-652-8132
Mailing Address - Fax:310-659-3815
Practice Address - Street 1:8631 W 3RD ST
Practice Address - Street 2:SUITE 615E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5901
Practice Address - Country:US
Practice Address - Phone:310-652-8132
Practice Address - Fax:310-659-3815
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG0494642086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG49464KMedicare PIN
C86940Medicare UPIN
CAWG49464DMedicare PIN