Basic Information
| Provider Information | |||||||||
| NPI: | 1346438108 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WING EYECARE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WING EYECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8340 COLERAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452393916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132459099 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8340 COLERAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452393916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132459099 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NAGY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 5139218433 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4131 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2200994 | 01 | UHC | OTHER | 301446570005 | 01 | MEDICAL MUTUAL | OTHER | 4131 | 01 | OH | OHIO LICENSE | OTHER | 000000328646 | 01 | ANTHEM | OTHER |