Provider Demographics
NPI:1902260714
Name:MARK S WAGNER MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MARK S WAGNER MD, A MEDICAL CORPORATION
Other - Org Name:OC COMPREHENSIVE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-558-8038
Mailing Address - Street 1:261 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1529
Mailing Address - Country:US
Mailing Address - Phone:310-218-3892
Mailing Address - Fax:
Practice Address - Street 1:515 CABRILLO PARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5016
Practice Address - Country:US
Practice Address - Phone:714-558-8038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003992261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center