Provider Demographics
NPI:1407126576
Name:WAGNER, BRETT JAMES (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:JAMES
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 1:5606 SW LEE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9688
Mailing Address - Country:US
Mailing Address - Phone:580-536-0000
Mailing Address - Fax:580-536-2205
Practice Address - Street 1:5606 SW LEE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9688
Practice Address - Country:US
Practice Address - Phone:580-536-0000
Practice Address - Fax:580-536-2205
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2718152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist