Provider Demographics
NPI:1437316957
Name:MACSORLEY, RENEE WAGNER
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:WAGNER
Last Name:MACSORLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9450 PENNSYLVANIA AVE
Mailing Address - Street 2:STE. 15
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3665
Mailing Address - Country:US
Mailing Address - Phone:301-599-6300
Mailing Address - Fax:
Practice Address - Street 1:9450 PENNSYLVANIA AVE
Practice Address - Street 2:STE. 15
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3665
Practice Address - Country:US
Practice Address - Phone:301-599-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC023053600Medicaid
MD30877OtherKAISER PERMANENTE
MD468228900Medicaid
DC406540466OtherMEDICARE RR
MD468228900Medicaid
DC023053600Medicaid