Provider Demographics
NPI:1114993789
Name:WAGNER, THOMAS JEFFREY (OD MS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JEFFREY
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:540 ROUTE 148
Mailing Address - Street 2:
Mailing Address - City:KILLINGWORTH
Mailing Address - State:CT
Mailing Address - Zip Code:06419-1107
Mailing Address - Country:US
Mailing Address - Phone:860-405-5555
Mailing Address - Fax:
Practice Address - Street 1:12 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2809
Practice Address - Country:US
Practice Address - Phone:860-536-1313
Practice Address - Fax:860-572-7770
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300015498Medicare PIN
T98110Medicare UPIN