Provider Demographics
NPI:1013052257
Name:WAGNER, FREDERICK JOSEPH JR (OD)
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:JOSEPH
Last Name:WAGNER
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 KIMBALL RD
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:MA
Mailing Address - Zip Code:01741
Mailing Address - Country:US
Mailing Address - Phone:978-371-2337
Mailing Address - Fax:978-371-2297
Practice Address - Street 1:101 KIMBALL RD
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:MA
Practice Address - Zip Code:01741
Practice Address - Country:US
Practice Address - Phone:978-371-2337
Practice Address - Fax:978-371-2297
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0320668Medicaid
MA0320668Medicaid