Provider Demographics
NPI:1396714812
Name:MEYER, WESLEY (OD)
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:MEYER
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 1:3329 N RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1063
Mailing Address - Country:US
Mailing Address - Phone:920-380-2715
Mailing Address - Fax:920-608-2755
Practice Address - Street 1:3329 N RICHMOND ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1063
Practice Address - Country:US
Practice Address - Phone:920-380-2715
Practice Address - Fax:920-608-2755
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38577400Medicaid
WIT86523Medicare UPIN
WI38577400Medicaid