Organization
MERCED RADIOLOGY MEDICAL GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK A WAGNER DO (DIRECTOR)
(209) 342-2300
Entity
Organization
Contact information
Practice address
731 E YOSEMITE AVE, SUITE B-170, MERCED, CA 95340-8039
(209) 342-2300
(209) 524-4240
Mailing address
4301 NORTHSTAR WAY, MODESTO, CA 95356-9262
(209) 342-2300
(209) 524-4240
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
8126
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
GR0005280
—
CA
05
—
GR0005281
—
CA
05
—
GR0005282
—
CA
05
—
GR0005283
—
CA
05
—
GR0005285
—
CA
05
—
GR0005286
—
CA
05
—
GR0005287
—
CA
05
—
GR0005289
—
CA
01
—
ZZZ25145Z
BLUE SHIELD
CA
Enumeration date
11/02/2005
Last updated
10/16/2008
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