Provider Demographics
NPI:1316644537
Name:WAGNER, CLARA DURIE (OD)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:DURIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 BITTERSWEET DR
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-1402
Mailing Address - Country:US
Mailing Address - Phone:419-953-2319
Mailing Address - Fax:
Practice Address - Street 1:2155 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1705
Practice Address - Country:US
Practice Address - Phone:419-228-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.007110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist