Provider Demographics
NPI:1770630733
Name:WAGNER, DENNIS M (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 CURRY FORD RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-3300
Mailing Address - Country:US
Mailing Address - Phone:407-894-9998
Mailing Address - Fax:407-894-5512
Practice Address - Street 1:2901 CURRY FORD RD
Practice Address - Street 2:SUITE 214
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-3300
Practice Address - Country:US
Practice Address - Phone:407-894-9998
Practice Address - Fax:407-894-5512
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOPC001701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19791Medicare PIN