| Doctor Name: | MYRON H WAGNER |
| NPI Number: | 1669750600 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 105 1/2 W Walnut St Oglesby, IL - 613481215 |
| Business Phone Number: | 8158839822 |
| Business Fax Number: | 8158839822 |
| Mailing Address: | 105 1/2 W Walnut St, OGLESBY |
| State: | IL |
| Postal Code: | 613481215 |
| Phone Number: | 8158839822 |
| Fax Number: | 8158839822 |
| NPI Enumeration Date: | 07/25/2011 |
| NPI Last Update Date: | 08/20/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |