Provider Demographics
NPI:1710154430
Name:WONCH, KATHERINE (OD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WONCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 LONESOME ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448
Mailing Address - Country:US
Mailing Address - Phone:985-626-5568
Mailing Address - Fax:985-777-9090
Practice Address - Street 1:4050 LONESOME ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448
Practice Address - Country:US
Practice Address - Phone:985-626-5568
Practice Address - Fax:985-777-9090
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1360-494T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1477648Medicaid
LA5DF11Medicare PIN