Healthcare Provider Details

I. General information

NPI: 1396037628
Provider Name (Legal Business Name): EGGERT & EGGERT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E MAGNOLIA AVE
MANITOWOC WI
54220-2256
US

IV. Provider business mailing address

700 E MAGNOLIA AVE
MANITOWOC WI
54220-2256
US

V. Phone/Fax

Practice location:
  • Phone: 920-686-1000
  • Fax:
Mailing address:
  • Phone: 920-686-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2292
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000047354
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerMEDICARE

VIII. Authorized Official

Name: STEVEN D EGGERT
Title or Position: OWNER/DOCTOR
Credential: OD
Phone: 920-686-1000