Provider Demographics
NPI:1447246046
Name:WEGNER, JON ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:ROBERT
Last Name:WEGNER
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 1:1120 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-3028
Mailing Address - Country:US
Mailing Address - Phone:262-637-7917
Mailing Address - Fax:262-637-6786
Practice Address - Street 1:1120 GROVE AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-3028
Practice Address - Country:US
Practice Address - Phone:262-637-7917
Practice Address - Fax:262-637-6786
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38594800Medicaid
WI38594800Medicaid
WIU56733Medicare UPIN