Provider Demographics
NPI:1821113697
Name:JOHN WARREN, OD SC
Entity Type:Organization
Organization Name:JOHN WARREN, OD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:262-752-2020
Mailing Address - Street 1:4060 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-3121
Mailing Address - Country:US
Mailing Address - Phone:272-752-2020
Mailing Address - Fax:262-752-2030
Practice Address - Street 1:4060 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-3121
Practice Address - Country:US
Practice Address - Phone:272-752-2020
Practice Address - Fax:262-752-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2527152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000047401Medicare PIN