Provider Demographics
NPI:1952339632
Name:WACHOLDER, MYRON BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:BRUCE
Last Name:WACHOLDER
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 1:2100 POWELL ST
Mailing Address - Street 2:STE 920
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2777
Mailing Address - Fax:
Practice Address - Street 1:24451 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3689
Practice Address - Country:US
Practice Address - Phone:714-837-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23430207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A234300Medicaid
CAA23535Medicare UPIN
CA00A234300Medicaid
CAWA23430CMedicare PIN