Provider Demographics
NPI:1669693628
Name:WIEGOLD, GEORGE K (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:K
Last Name:WIEGOLD
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 E WESTMINSTER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1840
Mailing Address - Country:US
Mailing Address - Phone:847-295-3290
Mailing Address - Fax:847-295-3291
Practice Address - Street 1:224 E WESTMINSTER RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1840
Practice Address - Country:US
Practice Address - Phone:847-295-3290
Practice Address - Fax:847-295-3291
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4167770001Medicare UPIN