Basic Information
| Provider Information | |||||||||
| NPI: | 1568551265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGONER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LUKE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | O. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 S GOVERNORS AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199044158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027345861 | ||||||||
| FaxNumber: | 3027341921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 13-0001302 | DE | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 11534593 | 01 | DE | CAQH | OTHER | 1568551265 | 01 | DE | NPI | OTHER | 1245251313 | 01 | GROUP NPI | OTHER | G00016 | 01 | MEDICARE GROUP PIN | OTHER | 018775H16 | 01 | MEDICARE PTAN | OTHER | 161525705 | 01 | DE | BCBS | OTHER | I3-0001302 | 01 | DE | LICENSE | OTHER | 1000039008 | 05 | DE | MEDICAID |