Provider Demographics
NPI:1003925892
Name:EYE CLINIC OF THE FOX VALLEY SC
Entity Type:Organization
Organization Name:EYE CLINIC OF THE FOX VALLEY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-236-3540
Mailing Address - Street 1:503 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2025
Mailing Address - Country:US
Mailing Address - Phone:920-236-3540
Mailing Address - Fax:920-236-3558
Practice Address - Street 1:503 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2025
Practice Address - Country:US
Practice Address - Phone:920-236-3540
Practice Address - Fax:920-236-3558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WITPA2317152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICI7005OtherRAILRAOD MEDICARE FOR OD
WI32781900Medicaid
WICP7959OtherRAILROAD MEDICARE
WICP7959OtherRAILROAD MEDICARE
WICI7005OtherRAILRAOD MEDICARE FOR OD