=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245660547
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALFRED A. WAGNER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 11/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8740 STATE ROUTE 434
-----------------------------------------------------
City | APALACHIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13732-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-625-2121
-----------------------------------------------------
Fax | 607-625-2131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 315
-----------------------------------------------------
City | APALACHIN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13732-4009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-625-2121
-----------------------------------------------------
Fax | 607-625-2131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPTOMETRIST
-----------------------------------------------------
Name | DR. ALFRED A. WAGNER
-----------------------------------------------------
Credential | O.D. (DOCTOR OF OPTO
-----------------------------------------------------
Telephone | 607-625-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TUV003310-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------