Provider Demographics
NPI:1356487995
Name:DELAFIELD VISION CENTER LTD
Entity Type:Organization
Organization Name:DELAFIELD VISION CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-646-7400
Mailing Address - Street 1:3175 GOLD RD
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2156
Mailing Address - Country:US
Mailing Address - Phone:262-646-7400
Mailing Address - Fax:262-646-7413
Practice Address - Street 1:3175 GOLD RD
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2156
Practice Address - Country:US
Practice Address - Phone:262-646-7400
Practice Address - Fax:262-646-7413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2609035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U53614Medicare UPIN
WI87685Medicare ID - Type Unspecified
WI1312740001Medicare NSC