Provider Demographics
NPI:1316987753
Name:WAGNER, ELLEN ROGERS (OD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:ROGERS
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 1:806 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3337
Mailing Address - Country:US
Mailing Address - Phone:904-356-7101
Mailing Address - Fax:904-356-7947
Practice Address - Street 1:806 RIVERSIDE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3337
Practice Address - Country:US
Practice Address - Phone:904-356-7101
Practice Address - Fax:904-356-7947
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2306152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20361OtherBCBS
20361AOtherBCBS
FL6183330002Medicare NSC
FL20361XMedicare PIN
FL6183330001Medicare NSC
FL410040102Medicare PIN
20361AOtherBCBS