Provider Demographics
NPI:1285686139
Name:WAGGONER, CHAD MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:WAGGONER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 BENJAMIN CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4807
Mailing Address - Country:US
Mailing Address - Phone:360-754-2817
Mailing Address - Fax:360-456-3894
Practice Address - Street 1:891 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4020
Practice Address - Country:US
Practice Address - Phone:401-331-7850
Practice Address - Fax:401-274-4739
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003598152W00000X
RIODTG00743152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU81024Medicare UPIN
WAAB16484Medicare ID - Type UnspecifiedMEDICARE NUMBER