Healthcare Provider Details

I. General information

NPI: 1215128806
Provider Name (Legal Business Name): TARA N VAN DE WYNGAERDE OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 14TH AVE
MENDOTA IL
61342-1412
US

IV. Provider business mailing address

700 14TH AVE
MENDOTA IL
61342-1412
US

V. Phone/Fax

Practice location:
  • Phone: 815-539-6291
  • Fax: 815-539-3035
Mailing address:
  • Phone: 815-539-6291
  • Fax: 815-539-3035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009989
License Number StateIL

VIII. Authorized Official

Name: TARA NICOLE VANDEWYNGAERDE
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 815-539-6291