Provider Demographics
NPI:1982676235
Name:GOGA, RAYMOND M (OD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:GOGA
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 1:515 N 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2910
Mailing Address - Country:US
Mailing Address - Phone:715-848-1246
Mailing Address - Fax:715-842-1660
Practice Address - Street 1:515 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2910
Practice Address - Country:US
Practice Address - Phone:715-848-1246
Practice Address - Fax:715-842-1660
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38704700Medicaid
WI38502100Medicaid
WI38707200Medicaid
WI000087201Medicare PIN
WIT62021Medicare UPIN
WI38707200Medicaid
WI000147955Medicare PIN
WI38502100Medicaid
WI1281090001Medicare NSC