Provider Demographics
NPI:1407930894
Name:WYMAN, ROBERT W (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:WYMAN
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 1:338 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-4146
Mailing Address - Country:US
Mailing Address - Phone:603-357-4090
Mailing Address - Fax:603-357-5081
Practice Address - Street 1:338 MAIN ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-4146
Practice Address - Country:US
Practice Address - Phone:603-357-4090
Practice Address - Fax:603-357-5081
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80002301Medicaid
NHT25660Medicare UPIN
NH80002301Medicaid