Healthcare Provider Details

I. General information

NPI: 1821113697
Provider Name (Legal Business Name): JOHN WARREN, OD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1139 S SUNNYSLOPE DR STE 203
MT PLEASANT WI
53406-3998
US

IV. Provider business mailing address

1139 S SUNNYSLOPE DR STE 203
MT PLEASANT WI
53406-3998
US

V. Phone/Fax

Practice location:
  • Phone: 272-752-2020
  • Fax: 262-292-5019
Mailing address:
  • Phone: 272-752-2020
  • Fax: 262-292-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2527
License Number StateWI

VIII. Authorized Official

Name: DR. JOHN E WARREN
Title or Position: OWNER
Credential: OD
Phone: 262-752-2020