Provider Demographics
NPI:1124012869
Name:VANDER WILT, CARA (OD)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:
Last Name:VANDER WILT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S 19TH CT
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-4725
Mailing Address - Country:US
Mailing Address - Phone:515-490-8103
Mailing Address - Fax:
Practice Address - Street 1:5501 NW 86TH ST STE 500
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1815
Practice Address - Country:US
Practice Address - Phone:515-270-0494
Practice Address - Fax:515-270-6463
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02289152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1124012869Medicaid
IA1124012869Medicaid
MOK71D288Medicare ID - Type Unspecified