Provider Demographics
NPI:1700933298
Name:WAGNER, RONALD T (O D)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:T
Last Name:WAGNER
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42142-0638
Mailing Address - Country:US
Mailing Address - Phone:270-651-8323
Mailing Address - Fax:270-651-8324
Practice Address - Street 1:115 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2903
Practice Address - Country:US
Practice Address - Phone:270-651-8323
Practice Address - Fax:270-651-8324
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYK808DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000047717OtherBLUE CROSS BLUE SHIELD
KY77008084Medicaid
KY611009062OtherTRI CARE
KY000000047717OtherBLUE CROSS BLUE SHIELD
KY611009062OtherTRI CARE
KY9019501Medicare PIN