Healthcare Provider Details

I. General information

NPI: 1689626582
Provider Name (Legal Business Name): RICHARD W. WAGNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N MAIN ST (US 19)
CHIEFLAND FL
32626
US

IV. Provider business mailing address

P.O. BOX 2622
CHIEFLAND FL
32644
US

V. Phone/Fax

Practice location:
  • Phone: 352-493-4448
  • Fax: 352-490-8100
Mailing address:
  • Phone: 135-249-3444
  • Fax: 135-249-0810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2419
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: