Basic Information
Provider Information | |||||||||
NPI: | 1770544603 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANDWEHR | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2825 HUNTERS TRL LOWR LEVEL | ||||||||
Address2: |   | ||||||||
City: | PORTAGE | ||||||||
State: | WI | ||||||||
PostalCode: | 539013429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087425522 | ||||||||
FaxNumber: | 6087453054 | ||||||||
Practice Location | |||||||||
Address1: | 1017 MAIN AVE | ||||||||
Address2: |   | ||||||||
City: | DE PERE | ||||||||
State: | WI | ||||||||
PostalCode: | 54115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203381700 | ||||||||
FaxNumber: | 9203381900 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2006 | ||||||||
LastUpdateDate: | 06/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2188 | WI | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 1770544603 | 05 | WI |   | MEDICAID | 38531700 | 05 | WI |   | MEDICAID |