Provider Demographics
NPI:1912984857
Name:WAGNER, THERESA EBANKS (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:EBANKS
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:LYNN
Other - Last Name:EBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5717 BALCONES DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4203
Mailing Address - Country:US
Mailing Address - Phone:512-327-7000
Mailing Address - Fax:512-314-1660
Practice Address - Street 1:925 STARWOOD DR
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613
Practice Address - Country:US
Practice Address - Phone:512-327-7000
Practice Address - Fax:512-259-3802
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6185207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX911391OtherBLOCK VISION
TX134257801Medicaid
TX87Y031Medicare PIN
TX3315223OtherBLUELINK
TX87Y031OtherBLUE CROSS BLUE SHIELD
TX6185OtherEYEMED
31667-006OtherDAVIS VISION
TX88Y384Medicare PIN
TX10011906OtherAMERIGROUP
F15223Medicare UPIN
SC180024703Medicare PIN
TX4411655OtherAETNA
TX134257803Medicaid
SC180026085Medicare PIN