Provider Demographics
NPI:1336360288
Name:BARRY A. WAGNER OD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BARRY A. WAGNER OD A PROFESSIONAL CORPORATION
Other - Org Name:VALLEY EYE PROFESSIOALS AN OPTOMETRIC CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
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 1:12229 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2576
Mailing Address - Country:US
Mailing Address - Phone:818-623-8900
Mailing Address - Fax:818-623-0978
Practice Address - Street 1:12229 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2576
Practice Address - Country:US
Practice Address - Phone:818-623-8900
Practice Address - Fax:818-623-0978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0051040Medicaid
CAGSD005410Medicaid
CAGSD005410Medicaid
CAWY190Medicare PIN
CAWOP5104AMedicare PIN