Provider Demographics
NPI:1710390919
Name:WAGNER, DIMITRA KOKKALIS
Entity Type:Individual
Prefix:
First Name:DIMITRA
Middle Name:KOKKALIS
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W PORTAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1412
Mailing Address - Country:US
Mailing Address - Phone:415-731-8080
Mailing Address - Fax:
Practice Address - Street 1:324 W PORTAL AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94127-1412
Practice Address - Country:US
Practice Address - Phone:415-731-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA172034174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty