Provider Demographics
NPI:1881815777
Name:BARRY A WAGNER OD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BARRY A WAGNER OD A PROFESSIONAL CORPORATION
Other - Org Name:OPTOMETRY EYE CARE CENTET DR. B WAGNER OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-985-2321
Mailing Address - Street 1:12000 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWWOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606
Mailing Address - Country:US
Mailing Address - Phone:818-985-2321
Mailing Address - Fax:818-985-6873
Practice Address - Street 1:12000 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWWOD
Practice Address - State:CA
Practice Address - Zip Code:91606
Practice Address - Country:US
Practice Address - Phone:818-985-2321
Practice Address - Fax:818-985-6873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0051040Medicaid
CAGSD005410Medicaid
CAGSD005410Medicaid
CAT69984Medicare UPIN
CASD0051040Medicaid