Provider Demographics
NPI:1477616431
Name:PALM, ANDREW S (OD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:S
Last Name:PALM
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 1:804 AMY DR
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9347
Mailing Address - Country:US
Mailing Address - Phone:608-317-3092
Mailing Address - Fax:
Practice Address - Street 1:3800 STATE ROAD 16
Practice Address - Street 2:STE 103 VALLEY VIEW MALL
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-1826
Practice Address - Country:US
Practice Address - Phone:608-781-2020
Practice Address - Fax:608-781-2445
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2939 - 035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000687961Medicare UPIN