Provider Demographics
NPI:1952589046
Name:DENNIS M. WAGNER OD
Entity type:Organization
Organization Name:DENNIS M. WAGNER OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MERLE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-894-9998
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19791Medicare PIN