Provider Demographics
NPI:1043213242
Name:WAGREICH, CARL (DPM)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:WAGREICH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23451 MADISON ST
Mailing Address - Street 2:STE 230
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4761
Mailing Address - Country:US
Mailing Address - Phone:310-373-0521
Mailing Address - Fax:310-791-1691
Practice Address - Street 1:23451 MADISON ST
Practice Address - Street 2:STE 230
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4761
Practice Address - Country:US
Practice Address - Phone:310-373-0521
Practice Address - Fax:310-791-1691
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2415213ES0103X, 213E00000X, 213ER0200X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24150Medicaid
CAT19194Medicare UPIN
CAWE2415AMedicare PIN