Provider Demographics
NPI:1194888255
Name:WAGNER, LEONARD ROBERT (DPM)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:ROBERT
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403
Mailing Address - Country:US
Mailing Address - Phone:818-995-8228
Mailing Address - Fax:818-995-1539
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-995-8228
Practice Address - Fax:818-995-1539
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1949213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E1949Medicare ID - Type Unspecified
T19151Medicare UPIN