Provider Demographics
NPI:1619192192
Name:WILLIAM W WAGNON MD PA
Entity Type:Organization
Organization Name:WILLIAM W WAGNON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-632-6111
Mailing Address - Street 1:2801 S JOHN REDDITT DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5666
Mailing Address - Country:US
Mailing Address - Phone:936-632-6111
Mailing Address - Fax:936-632-9182
Practice Address - Street 1:2801 S JOHN REDDITT DR
Practice Address - Street 2:SUITE B
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5666
Practice Address - Country:US
Practice Address - Phone:936-632-6111
Practice Address - Fax:936-632-9182
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM W. WAGNON MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8596-TG152W00000X
TXF2087207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093898701Medicaid
TX1902895345OtherNPI TYPE I
TX093898701Medicaid
TX093898701Medicaid