Provider Demographics
NPI:1518089341
Name:SCHWANDT, KARL GREGORY (OD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:GREGORY
Last Name:SCHWANDT
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 1:11013 67TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7548
Mailing Address - Country:US
Mailing Address - Phone:262-764-2023
Mailing Address - Fax:
Practice Address - Street 1:5497 S 76TH ST
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1130
Practice Address - Country:US
Practice Address - Phone:414-423-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2973-035152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38631200Medicaid