Provider Demographics
NPI:1134318694
Name:LAGRONE, WANDA GAIL (LDO)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:GAIL
Last Name:LAGRONE
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 E 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4716
Mailing Address - Country:US
Mailing Address - Phone:912-354-6445
Mailing Address - Fax:912-354-3393
Practice Address - Street 1:712 E 69TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4716
Practice Address - Country:US
Practice Address - Phone:912-354-6445
Practice Address - Fax:912-354-3393
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1041156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4106600001Medicare PIN