Individual
MARK S WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
515 CABRILLO PARK DR, SUITE 120, SANTA ANA, CA 92701-5016
(714) 558-8038
(714) 558-6033
Mailing address
PO BOX 94026, PASADENA, CA 91109-4026
(714) 558-8038
(714) 558-6033
Taxonomy
Speciality
Code
Description
License number
State
2084A0401X
Addiction Medicine (Psychiatry & Neurology) Physician
G42267
CA
208D00000X
General Practice Physician
Primary
G42267
CA
208VP0000X
Pain Medicine Physician
G42267
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G422670
—
CA
Enumeration date
06/17/2006
Last updated
09/01/2015
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