Provider Demographics
NPI:1306819636
Name:WYGONIK, EDWARD STEVEN (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:STEVEN
Last Name:WYGONIK
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 1:108 DRUMELLAN CT
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7222
Mailing Address - Country:US
Mailing Address - Phone:412-719-5926
Mailing Address - Fax:
Practice Address - Street 1:108 DRUMELLAN CT
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7222
Practice Address - Country:US
Practice Address - Phone:412-719-5926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4250152WC0802X, 152WP0200X, 152WS0006X, 152W00000X
PAOEG-000812152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
OH5350/T2259152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50054OtherDAVIS VISION ID
PAWY1395963OtherBLUE CRSS/SHLD PROV ID
PA3002066OtherAETNA PROVIDER ID
PA220961OtherCOLE MANAGED VISON ID
PA397597OtherNATIONAL VISION ADMIN. ID
PA1646983OtherHIGHMARK GROUP ID
PA220961OtherEYEMED ID
PA241675OtherHLTH AM/ASSR/ADVANTRA ID
PA101463734 0002Medicaid
PA313229OtherUPMC HEALTH PLAN ID
PA241675OtherHLTH AM/ASSR/ADVANTRA ID
PA410049273Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID
PA220961OtherEYEMED ID
PA083790Medicare ID - Type UnspecifiedMEDICARE 1 MAN GROUP ID