Healthcare Provider Details

I. General information

NPI: 1962453662
Provider Name (Legal Business Name): CRAIG L NEVERMANN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 N TRATT ST
WHITEWATER WI
53190-1205
US

IV. Provider business mailing address

128 N TRATT ST
WHITEWATER WI
53190-1205
US

V. Phone/Fax

Practice location:
  • Phone: 262-473-4514
  • Fax: 262-473-3161
Mailing address:
  • Phone: 262-473-4514
  • Fax: 262-473-3161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1509-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: