Provider Demographics
NPI:1790748903
Name:WAGNER, LOREE EBBINGHAUS (OD)
Entity Type:Individual
Prefix:DR
First Name:LOREE
Middle Name:EBBINGHAUS
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10071 WADSWORTH PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3804
Mailing Address - Country:US
Mailing Address - Phone:303-427-2020
Mailing Address - Fax:303-427-6197
Practice Address - Street 1:10071 WADSWORTH PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-3804
Practice Address - Country:US
Practice Address - Phone:303-427-2020
Practice Address - Fax:303-427-6197
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1775152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO532878Medicare ID - Type Unspecified
COU59947Medicare UPIN