Basic Information
| Provider Information | |||||||||
| NPI: | 1255352258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEVEN WIGDOR O.D. P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17941 BISCAYNE BLVD | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331602502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059310225 | ||||||||
| FaxNumber: | 3059310238 | ||||||||
| Practice Location | |||||||||
| Address1: | 17941 BISCAYNE BLVD | ||||||||
| Address2: | |||||||||
| City: | AVENTURA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331602502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3059310225 | ||||||||
| FaxNumber: | 3059310238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | WIGDOR | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3059310225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1791 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | Q0243 | 01 | FL | MEDICARE GROUP PTAN | OTHER | 078392701 | 05 | FL | MEDICAID | 582102001 | 01 | FL | MEDICARE DME | OTHER |