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General NPI Number Information
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NPI Number | 1689626582
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Entity Type | Individual
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Provider Name | RICHARD W. WAGNER OD
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Gender | Male
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 09/11/2018
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Provider Practice Location Address
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Address Line | 218 N MAIN ST (US 19)
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City | CHIEFLAND
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State | FL
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Zip | 32626
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Country | US
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Telephone | 352-493-4448
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Fax | 352-490-8100
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Provider Business Mailing Address
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Address Line | P.O. BOX 2622
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City | CHIEFLAND
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State | FL
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Zip | 32644
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Country | US
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Telephone | 135-249-3444
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Fax | 135-249-0810
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC2419
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License Number State | FL
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