Provider Demographics
NPI:1922071646
Name:WAGNER, BARRY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:ALAN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 FREMANTLE LN
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-3113
Mailing Address - Country:US
Mailing Address - Phone:818-880-2020
Mailing Address - Fax:818-880-1888
Practice Address - Street 1:12229 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2576
Practice Address - Country:US
Practice Address - Phone:818-880-2020
Practice Address - Fax:818-880-1888
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5104TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005410Medicaid
CASD0051040Medicaid
CAT69984Medicare UPIN
CAWOP5104AMedicare PIN
CAWY190Medicare PIN