Provider Demographics
NPI:1710065727
Name:WAGGONER, LARRY L (DOCTOR OF OPTOMETRY)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:L
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:DOCTOR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12134 MT MESA RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240
Mailing Address - Country:US
Mailing Address - Phone:760-379-3602
Mailing Address - Fax:760-379-2232
Practice Address - Street 1:12134 MT MESA RD
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240
Practice Address - Country:US
Practice Address - Phone:760-379-3602
Practice Address - Fax:760-379-2232
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6133T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T10240Medicare UPIN