Provider Demographics
NPI:1821078999
Name:WAGENER, ROBBIN W (OD)
Entity Type:Individual
Prefix:MRS
First Name:ROBBIN
Middle Name:W
Last Name:WAGENER
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 1:1180 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3190
Mailing Address - Country:US
Mailing Address - Phone:734-243-5300
Mailing Address - Fax:734-243-9956
Practice Address - Street 1:3165 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4348
Practice Address - Country:US
Practice Address - Phone:419-698-2350
Practice Address - Fax:419-698-8669
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004474152W00000X
OH4152152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH786172Medicaid
OH9310791Medicare PIN
OH4082176Medicare PIN
MI0N14190Medicare PIN
OH4082175Medicare PIN
410048424Medicare PIN
MIN14190009Medicare PIN
OH4082171Medicare PIN
MI0N55410Medicare PIN
OHT89084Medicare UPIN
OH9310793Medicare PIN
OH9310794Medicare PIN