Provider Demographics
NPI:1952824211
Name:WAGONER, PETER STEVEN (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:STEVEN
Last Name:WAGONER
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 OLD RIVERHEAD RD
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-1401
Mailing Address - Country:US
Mailing Address - Phone:631-903-3348
Mailing Address - Fax:
Practice Address - Street 1:16 OLD RIVERHEAD RD
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-1401
Practice Address - Country:US
Practice Address - Phone:631-903-3348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009237152W00000X
WAOD60770099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist