Healthcare Provider Details

I. General information

NPI: 1457463150
Provider Name (Legal Business Name): WILLIAM SCOTT WAGNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 ANDERSON RD STE 1
DAVIS CA
95616-3505
US

IV. Provider business mailing address

1700 ALHAMBRA BLVD STE 202
SACRAMENTO CA
95816-7050
US

V. Phone/Fax

Practice location:
  • Phone: 530-756-5040
  • Fax: 530-756-9140
Mailing address:
  • Phone: 916-731-8040
  • Fax: 916-454-4152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT9116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: