Provider Demographics
NPI:1780748988
Name:RAYMOND M GOGA
Entity type:Organization
Organization Name:RAYMOND M GOGA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-253-2157
Mailing Address - Street 1:601 S WEBB ST
Mailing Address - Street 2:
Mailing Address - City:WITTENBERG
Mailing Address - State:WI
Mailing Address - Zip Code:54499-9042
Mailing Address - Country:US
Mailing Address - Phone:715-253-2157
Mailing Address - Fax:715-253-3457
Practice Address - Street 1:601 S WEBB ST
Practice Address - Street 2:
Practice Address - City:WITTENBERG
Practice Address - State:WI
Practice Address - Zip Code:54499-9042
Practice Address - Country:US
Practice Address - Phone:715-253-2157
Practice Address - Fax:715-253-3457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38502100Medicaid
WI0325340003Medicare NSC
WIT62021Medicare UPIN
WI000087201Medicare PIN