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General NPI Number Information
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NPI Number | 1376687814
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Entity Type | Individual
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Provider Name | IRVEN ROBERT WAGNER O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/17/2007
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Last Update Date | 04/22/2009
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Provider Practice Location Address
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Address Line | 800 CODDINGTOWN CTR
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City | SANTA ROSA
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State | CA
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Zip | 95401-3511
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Country | US
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Telephone | 707-526-1881
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Fax | 707-542-2014
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Provider Business Mailing Address
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Address Line | 1945 PINER RD SPC 118
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City | SANTA ROSA
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State | CA
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Zip | 95403-6911
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Country | US
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Telephone | 707-526-1881
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Fax | 707-542-2014
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number | 8372TPA
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License Number State | CA
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