Provider Demographics
NPI:1720014525
Name:WAGMEISTER, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WAGMEISTER
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 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:STE 670W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2185
Mailing Address - Country:US
Mailing Address - Phone:310-828-5626
Mailing Address - Fax:310-828-2826
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:STE 670W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2185
Practice Address - Country:US
Practice Address - Phone:310-828-5626
Practice Address - Fax:310-828-2826
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41624174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G416240Medicaid
CAA92273Medicare UPIN
CAG41624Medicare ID - Type Unspecified