Provider Demographics
NPI:1902850977
Name:ANDERSON SCHALLER, KATRINA M (OD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:ANDERSON SCHALLER
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 1:2825 HUNTERS TRL LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3429
Mailing Address - Country:US
Mailing Address - Phone:608-742-5522
Mailing Address - Fax:608-745-3054
Practice Address - Street 1:2825 HUNTERS TRL LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3429
Practice Address - Country:US
Practice Address - Phone:608-742-5522
Practice Address - Fax:608-745-3054
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2983-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902850977Medicaid
WIP00199567Medicare PIN
WIK400176400Medicare PIN
WIP00256813Medicare PIN
WI000947810Medicare PIN
WI60485OtherDEAN HEALTH INSURANCE