Provider Demographics
NPI:1912566597
Name:BLANK, WILLIAM ALDEN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ALDEN
Last Name:BLANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5843 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7120
Mailing Address - Country:US
Mailing Address - Phone:608-788-4889
Mailing Address - Fax:
Practice Address - Street 1:W5843 VISTA DR
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-7120
Practice Address - Country:US
Practice Address - Phone:608-788-4889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18559207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology