Healthcare Provider Details

I. General information

NPI: 1871763862
Provider Name (Legal Business Name): WAYNE DOUGHERTY DBA WHEELING OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MARKET STREET
WHEELING WV
26003-2905
US

IV. Provider business mailing address

1101 MARKET STREET
WHEELING WV
26003-2905
US

V. Phone/Fax

Practice location:
  • Phone: 304-232-6501
  • Fax: 304-232-6502
Mailing address:
  • Phone: 304-232-6501
  • Fax: 304-232-6502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0507000045
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number05 7 00045
License Number StateWV

VIII. Authorized Official

Name: WAYNE DOUGHERTY
Title or Position: OWNER OPTICIAN
Credential:
Phone: 304-232-6501