Provider Demographics
NPI:1609932888
Name:WAGNER, PAUL (OD PLC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD PLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 W ELLIOT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-1620
Mailing Address - Country:US
Mailing Address - Phone:480-838-4044
Mailing Address - Fax:480-838-4072
Practice Address - Street 1:2955 W. ELLIOT RD.
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-838-4044
Practice Address - Fax:480-838-4072
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ587152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist