Provider Demographics
NPI:1124161872
Name:WAGNER, LLOYD DAVID (MD)
Entity type:Individual
Prefix:
First Name:LLOYD
Middle Name:DAVID
Last Name:WAGNER
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 1:223 24TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-2515
Mailing Address - Country:US
Mailing Address - Phone:888-886-5238
Mailing Address - Fax:888-886-9330
Practice Address - Street 1:223 24TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-2515
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA096105002085R0202X
CAG702262085R0202X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE75401Medicare UPIN