Provider Demographics
NPI:1700821709
Name:WAGNER, MARK S (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 94026
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-4026
Mailing Address - Country:US
Mailing Address - Phone:714-558-8038
Mailing Address - Fax:714-558-6033
Practice Address - Street 1:515 CABRILLO PARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5016
Practice Address - Country:US
Practice Address - Phone:714-558-8038
Practice Address - Fax:714-558-6033
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42267208D00000X, 208VP0000X, 2084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G422670Medicaid
A48890Medicare UPIN
CAHG42267AMedicare PIN