Provider Demographics
NPI:1992812671
Name:WACKER, MARGARET (MD)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:WACKER
Suffix:
Gender:F
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:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:909-777-3397
Mailing Address - Fax:909-422-8908
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:ARMC
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-580-6210
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG509811207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079700Medicaid
E87113Medicare UPIN
ZZZ13858ZMedicare ID - Type Unspecified