Healthcare Provider Details

I. General information

NPI: 1598980435
Provider Name (Legal Business Name): RICHARD WAGNER , OD,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N MAIN ST 218 N MAIN ST
CHIEFLAND FL
32626-0802
US

IV. Provider business mailing address

218 N MAIN ST P.O. BOX 2622
CHIEFLAND FL
32626-0802
US

V. Phone/Fax

Practice location:
  • Phone: 352-493-4448
  • Fax: 352-490-8100
Mailing address:
  • Phone: 352-493-4448
  • Fax: 352-490-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13825
License Number StateFL

VIII. Authorized Official

Name: RICHARD WAGNER
Title or Position: OPTOMETRY
Credential: OD
Phone: 352-493-4448