Individual
DR. BRET BOUTON WAGENHORST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1803 OLD OCILLA RD, TIFTON, GA 31794-1617
(229) 386-2181
(229) 386-2193
Mailing address
907 18TH ST E STE 400, TIFTON, GA 31794-3684
(229) 353-3450
(229) 353-6060
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
044138
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00760856A
—
GA
01
—
077471001
CIGNA
GA
01
—
180041335
RRMC
GA
Enumeration date
08/11/2006
Last updated
03/08/2021
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