Provider Demographics
NPI:1043498249
Name:WAGNER FAMILY EYECARE, PC
Entity type:Organization
Organization Name:WAGNER FAMILY EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:814-677-6636
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:PA
Mailing Address - Zip Code:16346-0307
Mailing Address - Country:US
Mailing Address - Phone:814-677-6636
Mailing Address - Fax:814-677-9562
Practice Address - Street 1:3285 STATE ROUTE 257
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2529
Practice Address - Country:US
Practice Address - Phone:814-677-6636
Practice Address - Fax:814-677-9562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
PA0EG000125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014195820006Medicaid
PA0014195820006Medicaid
PA038827Medicare UPIN
PAU80736Medicare UPIN
038827Medicare PIN