Provider Demographics
NPI:1114916665
Name:WAGNER, ALFRED A (OD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:M
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:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-0315
Mailing Address - Country:US
Mailing Address - Phone:607-625-2121
Mailing Address - Fax:607-625-2131
Practice Address - Street 1:8740 STATE ROUTE 434
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-4009
Practice Address - Country:US
Practice Address - Phone:607-625-2121
Practice Address - Fax:607-625-2131
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003310-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY31630BMedicare ID - Type Unspecified
0177080001Medicare NSC
NYT26341Medicare UPIN