Provider Demographics
NPI:1437768876
Name:WISCONSIN OPTOMETRIC EYE DOCTOR, S.C
Entity Type:Organization
Organization Name:WISCONSIN OPTOMETRIC EYE DOCTOR, S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-206-2418
Mailing Address - Street 1:2644 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-4921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17550 W BLUEMOUND RD STE D
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2928
Practice Address - Country:US
Practice Address - Phone:651-206-2418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty