Provider Demographics
NPI:1568551265
Name:WAGONER, ROBERT LUKE (O D)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LUKE
Last Name:WAGONER
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-5861
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:885 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4158
Practice Address - Country:US
Practice Address - Phone:302-734-5861
Practice Address - Fax:302-734-1921
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE13-0001302152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE11534593OtherCAQH
DE1568551265OtherNPI
1245251313OtherGROUP NPI
G00016OtherMEDICARE GROUP PIN
018775H16OtherMEDICARE PTAN
DE161525705OtherBCBS
DEI3-0001302OtherLICENSE
DE1000039008Medicaid
51-0270915OtherFEDERIN EIN
1245251313OtherGROUP NPI