Provider Demographics
NPI:1902026206
Name:WAGNER, JAMES P (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:P
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:5300 S 76TH ST
Mailing Address - Street 2:STE 690
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1102
Mailing Address - Country:US
Mailing Address - Phone:414-855-0469
Mailing Address - Fax:414-855-0492
Practice Address - Street 1:5300 S 76TH ST
Practice Address - Street 2:STE 690
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1102
Practice Address - Country:US
Practice Address - Phone:414-855-0469
Practice Address - Fax:414-855-0492
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2645-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI810571047OtherTAX ID
WIT21464Medicare UPIN
WI4800030001Medicare NSC
WI0004272879Medicare PIN