Provider Demographics
NPI:1336130087
Name:WAGNER, MARK ANDREW (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:WAGNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NORTHSTAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-524-4240
Practice Address - Street 1:36680 CLOVERLEAF AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8519
Practice Address - Country:US
Practice Address - Phone:209-489-9347
Practice Address - Fax:209-720-0107
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A52592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A52590OtherBLUE SHIELD
CA00AX52590Medicaid
CA020A52590Medicare ID - Type Unspecified
CA020A52590OtherBLUE SHIELD