=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952824211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER STEVEN WAGONER OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2017
-----------------------------------------------------
Last Update Date | 08/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 OLD RIVERHEAD RD
-----------------------------------------------------
City | WESTHAMPTON BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11978-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-903-3348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 OLD RIVERHEAD RD STE B
-----------------------------------------------------
City | WESTHAMPTON BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11978-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-898-5000
-----------------------------------------------------
Fax | 631-824-4303
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OD60770099
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 009237
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------