Provider Demographics
NPI:1245568682
Name:HERRON, DESIREE MONIK (OD)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MONIK
Last Name:HERRON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:MONIK
Other - Last Name:KAEBISCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1640 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6406
Mailing Address - Country:US
Mailing Address - Phone:920-390-2971
Mailing Address - Fax:920-390-2974
Practice Address - Street 1:1640 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6406
Practice Address - Country:US
Practice Address - Phone:920-390-2971
Practice Address - Fax:920-390-2974
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3168-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI476900006OtherMEDICARE ID