Provider Demographics
NPI:1295754778
Name:WAGNER, DAVID A (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3285 STATE ROUTE 257
Mailing Address - Street 2:PO BOX 307
Mailing Address - City:SENECA
Mailing Address - State:PA
Mailing Address - Zip Code:16346-2529
Mailing Address - Country:US
Mailing Address - Phone:814-677-6636
Mailing Address - Fax:814-677-9562
Practice Address - Street 1:3285 STATE ROUTE 257
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2529
Practice Address - Country:US
Practice Address - Phone:814-677-6636
Practice Address - Fax:814-677-9562
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000125152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018040170003Medicaid
PA0925200001Medicare NSC
PA038827Medicare PIN
PAU80736Medicare UPIN