Healthcare Provider Details

I. General information

NPI: 1992737704
Provider Name (Legal Business Name): TODD WILLIAM WILD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E ANN ST
WEYAUWEGA WI
54983-8532
US

IV. Provider business mailing address

PO BOX 350
WEYAUWEGA WI
54983-0350
US

V. Phone/Fax

Practice location:
  • Phone: 920-867-3131
  • Fax: 920-867-3408
Mailing address:
  • Phone: 920-867-3131
  • Fax: 920-867-3408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2346
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: