Basic Information
| Provider Information | |||||||||
| NPI: | 1841458023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | KLAUS | ||||||||
| MiddleName: | WOLFGANG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | HEMATOLOGY/ONCOLOGY | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3350 LA JOLLA VILLAGE DR | ||||||||
| Address2: | VA HEMATOLOGY/ONCOLOGY | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921610002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585528585 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2008 | ||||||||
| LastUpdateDate: | 01/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | A119744 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 207614301 | 05 | TX | MEDICAID | A119744 | 01 | CA | STATE LICENSE | OTHER |