Basic Information
| Provider Information | |||||||||
| NPI: | 1992350375 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT EYE CARE OF WISCONSIN SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10425 W NORTH AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148776414 | ||||||||
| FaxNumber: | 4143865245 | ||||||||
| Practice Location | |||||||||
| Address1: | 10425 W NORTH AVE STE 245 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148776414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2019 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VUKICH | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4148776414 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.