Basic Information
| Provider Information | |||||||||
| NPI: | 1316987753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | ROGERS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 806 RIVERSIDE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043567101 | ||||||||
| FaxNumber: | 9043567947 | ||||||||
| Practice Location | |||||||||
| Address1: | 806 RIVERSIDE AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043567101 | ||||||||
| FaxNumber: | 9043567947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2306 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 20361 | 01 | FL | BCBS | OTHER | 20361A | 01 | BCBS | OTHER |