Basic Information
| Provider Information | |||||||||
| NPI: | 1386786754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SATEREN | ||||||||
| FirstName: | CAMILE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOLL | ||||||||
| OtherFirstName: | CAMILE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1615 MAPLE LANE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855513 | ||||||||
| FaxNumber: | 7156824022 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 MAPLE LANE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156855513 | ||||||||
| FaxNumber: | 7156824022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2424 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000012004 | 01 | WI | MEDICARE CLINIC ID | OTHER | 38593600 | 05 | WI | MEDICAID | 120040006 | 01 | WI | MEDICARE PTAN | OTHER | 204728664 | 01 | WI | CLINIC TAX ID | OTHER | 5705960001 | 01 | WI | MEDICARE DMERC ID | OTHER |