Healthcare Provider Details
I. General information
NPI: 1306819636
Provider Name (Legal Business Name): EDWARD STEVEN WYGONIK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y
II. Dates (important events)
Enumeration Date: 02/08/2006
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
108 DRUMELLAN CT
SAINT JOHNS FL
32259-7222
US
IV. Provider business mailing address
108 DRUMELLAN CT
SAINT JOHNS FL
32259-7222
US
V. Phone/Fax
- Phone: 412-719-5926
- Fax:
- Phone: 412-719-5926
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WC0802X |
| Taxonomy | Corneal and Contact Management Optometrist |
| License Number | OPC 4250 |
| License Number State | FL |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WP0200X |
| Taxonomy | Pediatric Optometrist |
| License Number | OPC 4250 |
| License Number State | FL |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WS0006X |
| Taxonomy | Sports Vision Optometrist |
| License Number | OPC 4250 |
| License Number State | FL |
| # 4 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | OPC 4250 |
| License Number State | FL |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | OEG-000812 |
| License Number State | PA |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 5350/T2259 |
| License Number State | OH |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WC0802X |
| Taxonomy | Corneal and Contact Management Optometrist |
| License Number | OEG-000812 |
| License Number State | PA |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WC0802X |
| Taxonomy | Corneal and Contact Management Optometrist |
| License Number | 5350/T2259 |
| License Number State | OH |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WP0200X |
| Taxonomy | Pediatric Optometrist |
| License Number | OEG-000812 |
| License Number State | PA |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WP0200X |
| Taxonomy | Pediatric Optometrist |
| License Number | 5350/T2259 |
| License Number State | OH |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WS0006X |
| Taxonomy | Sports Vision Optometrist |
| License Number | OEG-000812 |
| License Number State | PA |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WS0006X |
| Taxonomy | Sports Vision Optometrist |
| License Number | 5350/T2259 |
| License Number State | OH |
| # 13 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WX0102X |
| Taxonomy | Occupational Vision Optometrist |
| License Number | OEG-000812 |
| License Number State | PA |
| # 14 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152WX0102X |
| Taxonomy | Occupational Vision Optometrist |
| License Number | 5350/T2259 |
| License Number State | OH |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
