Healthcare Provider Details

I. General information

NPI: 1013907310
Provider Name (Legal Business Name): MELISSA MCGOWAN TERRILL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA MARIE MCGOWAN O.D.

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 12/13/2020
Certification Date: 12/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

IV. Provider business mailing address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

V. Phone/Fax

Practice location:
  • Phone: 608-825-3008
  • Fax: 608-825-3794
Mailing address:
  • Phone: 608-825-3008
  • Fax: 608-825-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3026-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: