Provider Demographics
NPI:1316094147
Name:WAGNER OPTICAL INC
Entity type:Organization
Organization Name:WAGNER OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:716-845-6080
Mailing Address - Street 1:945 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14212-1218
Mailing Address - Country:US
Mailing Address - Phone:716-845-6080
Mailing Address - Fax:716-845-0167
Practice Address - Street 1:945 BROADWAY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14212-1218
Practice Address - Country:US
Practice Address - Phone:716-845-6080
Practice Address - Fax:716-845-0167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
17227OtherSPECTERA
49762OtherFIDELIS
7309888OtherINDEPENDENT HEALTH
00011397201OtherUNIVERA
000390029003OtherCOMMUNITY BLUE
NY3364OtherEYEMED
NY01677123Medicaid
000390029003OtherCOMMUNITY BLUE