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General NPI Number Information
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NPI Number | 1841201134
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Entity Type | Individual
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Provider Name | BRET BOUTON WAGENHORST M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 03/08/2021
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Provider Practice Location Address
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Address Line | 1803 OLD OCILLA RD
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City | TIFTON
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State | GA
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Zip | 31794-1617
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Country | US
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Telephone | 229-386-2181
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Fax | 229-386-2193
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Provider Business Mailing Address
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Address Line | 907 18TH ST E STE 400
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City | TIFTON
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State | GA
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Zip | 31794-3684
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Country | US
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Telephone | 229-353-3450
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Fax | 229-353-6060
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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 | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 044138
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License Number State | GA
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