Provider Demographics
NPI:1689626582
Name:WAGNER, RICHARD W (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2622
Mailing Address - Street 2:
Mailing Address - City:CHIEFLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32644
Mailing Address - Country:US
Mailing Address - Phone:135-249-3444
Mailing Address - Fax:135-249-0810
Practice Address - Street 1:218 N MAIN ST (US 19)
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626
Practice Address - Country:US
Practice Address - Phone:352-493-4448
Practice Address - Fax:352-490-8100
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist