Provider Demographics
NPI:1841458023
Name:WAGNER, KLAUS WOLFGANG (MD PHD)
Entity type:Individual
Prefix:DR
First Name:KLAUS
Middle Name:WOLFGANG
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 LA JOLLA VILLAGE DR
Mailing Address - Street 2:HEMATOLOGY/ONCOLOGY
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0002
Mailing Address - Country:US
Mailing Address - Phone:858-552-8585
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:VA HEMATOLOGY/ONCOLOGY
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-24
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119744207RX0202X
TXN4189390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207614301Medicaid
CAA119744OtherSTATE LICENSE
TX207614301Medicaid