Provider Demographics
NPI:1043260144
Name:WIGHT, DONALD E (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:E
Last Name:WIGHT
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 1:6256 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4418
Mailing Address - Country:US
Mailing Address - Phone:815-708-7083
Mailing Address - Fax:815-904-6294
Practice Address - Street 1:6256 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4418
Practice Address - Country:US
Practice Address - Phone:815-708-7083
Practice Address - Fax:815-904-6294
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.007443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07989130001Medicare ID - Type Unspecified
ILT39113Medicare UPIN
IL787730Medicare ID - Type Unspecified