Healthcare Provider Details

I. General information

NPI: 1891812749
Provider Name (Legal Business Name): RANDY JOSEPH WILD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MAPLE ST
NEENAH WI
54956-4122
US

IV. Provider business mailing address

1111 MAPLE ST
NEENAH WI
54956-4122
US

V. Phone/Fax

Practice location:
  • Phone: 920-722-7411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1706
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1706
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number1706
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number1706
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1706
License Number StateWI
# 6
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number1706
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: