Provider Demographics
NPI:1700938867
Name:BYERS, MARY JO (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JO
Last Name:BYERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 N MAIN ST
Mailing Address - Street 2:P.O. BOX 302
Mailing Address - City:IOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54945-9120
Mailing Address - Country:US
Mailing Address - Phone:715-445-3553
Mailing Address - Fax:715-445-4970
Practice Address - Street 1:135 N MAIN ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:WI
Practice Address - Zip Code:54945-9120
Practice Address - Country:US
Practice Address - Phone:715-445-3553
Practice Address - Fax:715-445-4970
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38585900Medicaid
WI410031113Medicare PIN
WI38585900Medicaid
WIU37087Medicare UPIN
WI000290166Medicare PIN