Provider Demographics
NPI:1720180383
Name:WAGMAN, LAWRENCE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:DAVID
Last Name:WAGMAN
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 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 SAN BERNARDINO ROAD
Practice Address - Street 2:SUITE 1100
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4952
Practice Address - Country:US
Practice Address - Phone:909-949-2242
Practice Address - Fax:909-981-5783
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55578208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G555780Medicaid
CAWG55578AMedicare ID - Type Unspecified
CA00G555780Medicaid