Individual
ROBERT LUKE WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O. D.
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
13-0001302
DE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
018775H16
MEDICARE PTAN
—
05
—
1000039008
—
DE
01
—
11534593
CAQH
DE
01
—
1245251313
GROUP NPI
—
01
—
1568551265
NPI
DE
01
—
161525705
BCBS
DE
01
—
G00016
MEDICARE GROUP PIN
—
01
—
I3-0001302
LICENSE
DE
Enumeration date
10/12/2006
Last updated
11/16/2010
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