Provider Demographics
NPI:1275687105
Name:ROMANAK, JOSEPH
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:ROMANAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7323 60TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3542
Mailing Address - Country:US
Mailing Address - Phone:262-942-9899
Mailing Address - Fax:262-942-0124
Practice Address - Street 1:7323 60TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3542
Practice Address - Country:US
Practice Address - Phone:262-942-9899
Practice Address - Fax:262-942-0124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2200152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391760322OtherTAX ID
WI000087425Medicare ID - Type UnspecifiedPROVIDER #
WI391760322OtherTAX ID
WI0871100001Medicare NSC