Provider Demographics
NPI:1699839845
Name:WAGNER, ROCHELLE M (OD)
Entity type:Individual
Prefix:DR
First Name:ROCHELLE
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4687 MORSE RD
Mailing Address - Street 2:SEARS OPTICAL
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1375
Mailing Address - Country:US
Mailing Address - Phone:614-478-7244
Mailing Address - Fax:614-478-4507
Practice Address - Street 1:4687 MORSE RD
Practice Address - Street 2:SEARS OPTICAL
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1375
Practice Address - Country:US
Practice Address - Phone:614-478-7244
Practice Address - Fax:614-478-4507
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4885152W00000X
VA0618001173152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist