Provider Demographics
NPI:1295719631
Name:WAGNER, ALAN LEWIS (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:LEWIS
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 KEMPSVILLE CIR STE 250B
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3933
Mailing Address - Country:US
Mailing Address - Phone:757-481-4400
Mailing Address - Fax:757-481-1285
Practice Address - Street 1:6160 KEMPSVILLE CIR STE 120B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3933
Practice Address - Country:US
Practice Address - Phone:757-481-4400
Practice Address - Fax:757-481-1285
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039260207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006396097Medicaid
VA27210OtherOPTIMA
VA202826OtherCIGNA
VA044061OtherANTHEM
VA044061OtherANTHEM
VA044061OtherANTHEM