Healthcare Provider Details

I. General information

NPI: 1639183734
Provider Name (Legal Business Name): WILLIAM JOHN HARTMAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 JEFFERSON ST S
WADENA MN
56482-1533
US

IV. Provider business mailing address

1508 2ND ST SW
WADENA MN
56482-2115
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-1456
  • Fax: 218-631-3213
Mailing address:
  • Phone: 218-631-2078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2355
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: