Basic Information
| Provider Information | |||||||||
| NPI: | 1083176952 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MYEYEDR OPTOMETRY OF WISCONSIN, LLC | ||||||||
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| OtherOrganizationName: | MYEYEDR. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MARTIN DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530219455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626929000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2019 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | DOWNES | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7038478899 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.