Provider Demographics
NPI:1780756593
Name:WAGNER, GAIL MONA (MD)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:MONA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GAIL
Other - Middle Name:MONA
Other - Last Name:OLENICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 MERCED STREET
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4201
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 MERCED STREET
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37771207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G377710Medicaid
F18749Medicare UPIN
CA00G377710Medicaid