Provider Demographics
NPI:1376687814
Name:WAGNER, IRVEN ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:IRVEN
Middle Name:ROBERT
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 1:1945 PINER RD SPC 118
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-6911
Mailing Address - Country:US
Mailing Address - Phone:707-526-1881
Mailing Address - Fax:707-542-2014
Practice Address - Street 1:800 CODDINGTOWN CTR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-3511
Practice Address - Country:US
Practice Address - Phone:707-526-1881
Practice Address - Fax:707-542-2014
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8372TPA152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy