Provider Demographics
NPI:1063561587
Name:WAGNER OPTOMETRY PC
Entity type:Organization
Organization Name:WAGNER OPTOMETRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-427-2020
Mailing Address - Street 1:10071 WADSWORTH PKWY
Mailing Address - Street 2:STE. 200
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80021-3804
Mailing Address - Country:US
Mailing Address - Phone:303-427-2020
Mailing Address - Fax:303-427-6197
Practice Address - Street 1:10071 WADSWORTH PKWY
Practice Address - Street 2:STE. 200
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80021-3804
Practice Address - Country:US
Practice Address - Phone:303-427-2020
Practice Address - Fax:303-427-6197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18-11667-0000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1790748903OtherNPI
CO1477515385OtherNPI
CO5461250001Medicare NSC
COU69676Medicare UPIN
CO1790748903OtherNPI
COU62598Medicare UPIN
COC530138Medicare PIN