Provider Demographics
NPI:1053434035
Name:WAGNER, BRUCE (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24040 CAMINO DEL AVION STE E
Mailing Address - Street 2:
Mailing Address - City:MONARCH BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4005
Mailing Address - Country:US
Mailing Address - Phone:949-443-9110
Mailing Address - Fax:
Practice Address - Street 1:24040 CAMINO DEL AVION STE E
Practice Address - Street 2:
Practice Address - City:MONARCH BEACH
Practice Address - State:CA
Practice Address - Zip Code:92629-4005
Practice Address - Country:US
Practice Address - Phone:949-443-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6376152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6376Medicare ID - Type Unspecified
CA49210Medicare UPIN