Provider Demographics
NPI:1225023542
Name:FOSS, DYLAN J (OD)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:J
Last Name:FOSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 S KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6186
Mailing Address - Country:US
Mailing Address - Phone:920-223-7330
Mailing Address - Fax:
Practice Address - Street 1:1855 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6186
Practice Address - Country:US
Practice Address - Phone:920-223-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38602900Medicaid
WI38602900Medicaid
U65821Medicare UPIN