Active NPI
Gary Wagner, M.D.
- Dermatology Physician
- Modesto, CA
National Provider Identifier
1235160102
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- A24987
- Practice address
- 600 Coffee Rd
Modesto, CA 95355-4201 - Phone
- (209) 524-1211
- NPI assigned
- Jul 6, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | A24987 | CA | Primary |
Addresses
Primary practice location
600 Coffee Rd
Modesto, CA 95355-4201
Mailing address
600 Coffee Rd
Modesto, CA 95355-4201
Phone (209) 521-6097
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00A249871 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| A24987 | CA | MD | Dermatology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1152144000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1459468800000",
"number": "1235160102",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "600 COFFEE RD",
"city": "MODESTO",
"state": "CA",
"postal_code": "953554201",
"telephone_number": "209-521-6097"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "600 COFFEE RD",
"city": "MODESTO",
"state": "CA",
"postal_code": "953554201",
"telephone_number": "209-524-1211"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "GARY",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-06",
"last_updated": "2016-04-01",
"status": "A"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "",
"desc": "Dermatology",
"state": "CA",
"license": "A24987",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00A249871",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Modesto, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.