Provider Demographics
NPI:1598980435
Name:RICHARD WAGNER , OD,PA
Entity Type:Organization
Organization Name:RICHARD WAGNER , OD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRY
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-493-4448
Mailing Address - Street 1:218 N MAIN ST
Mailing Address - Street 2:P.O. BOX 2622
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32626-0802
Mailing Address - Country:US
Mailing Address - Phone:352-493-4448
Mailing Address - Fax:352-490-8100
Practice Address - Street 1:218 N MAIN ST
Practice Address - Street 2:218 N MAIN ST
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-0802
Practice Address - Country:US
Practice Address - Phone:352-493-4448
Practice Address - Fax:352-490-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty