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NPI Code Detail

MEDICARE: DR. JAMES P WAGNER OD

MEDICARE: DR. JAMES P WAGNER OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist2645-035WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1810571047OTHERWITAX ID

General Provider Information

NPI Number : 1902026206
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JAMES P WAGNER OD
Provider Business Mailing Address
First Line : 5300 S 76TH ST
Second Line : STE 690
City : GREENDALE
State : WI
Zip : 53129-1102
Country : US
Telephone Number : 414-855-0469
Fax Number : 414-855-0492
Provider Business Practice Location Address
First Line : 5300 S 76TH ST
Second Line : STE 690
City : GREENDALE
State : WI
Zip : 53129-1102
Country : US
Telephone Number : 414-855-0469
Fax Number : 414-855-0492
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/27/2007
Last Update Date : 07/29/2009

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Directions to “ DR. JAMES P WAGNER OD” Practice Location

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