Provider Demographics
NPI:1902895345
Name:WAGNON, WILLIAM WRIGHT
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:WRIGHT
Last Name:WAGNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 S JOHN REDDITT DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5666
Mailing Address - Country:US
Mailing Address - Phone:936-632-6111
Mailing Address - Fax:936-632-9182
Practice Address - Street 1:2801 S JOHN REDDITT DR
Practice Address - Street 2:SUITE B
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5666
Practice Address - Country:US
Practice Address - Phone:936-632-6111
Practice Address - Fax:936-632-9182
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2087207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093898701Medicaid
TXB27392Medicare UPIN
TX093898701Medicaid