Healthcare Provider Details

I. General information

NPI: 1881647030
Provider Name (Legal Business Name): RICHARD RAYMOND TOELLNER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 APPLETON RD
MENASHA WI
54952-1106
US

IV. Provider business mailing address

1640 APPLETON RD
MENASHA WI
54952-1106
US

V. Phone/Fax

Practice location:
  • Phone: 920-725-3752
  • Fax: 920-722-3195
Mailing address:
  • Phone: 920-725-3752
  • Fax: 920-722-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2340-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: