Provider Demographics
NPI:1841201134
Name:WAGENHORST, BRET BOUTON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRET
Middle Name:BOUTON
Last Name:WAGENHORST
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:907 18TH ST E STE 400
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3684
Mailing Address - Country:US
Mailing Address - Phone:229-353-3450
Mailing Address - Fax:229-353-6060
Practice Address - Street 1:1803 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-386-2181
Practice Address - Fax:229-386-2193
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-03-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA044138207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA077471001OtherCIGNA
GA00760856AMedicaid
GA180041335OtherRRMC