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General NPI Number Information
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NPI Number | 1003925892
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Entity Type | Organization
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Legal Business Name | EYE CLINIC OF THE FOX VALLEY SC
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 01/16/2013
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Provider Practice Location Address
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Address Line | 503 DOCTORS CT
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City | OSHKOSH
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State | WI
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Zip | 54901-2025
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Country | US
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Telephone | 920-236-3540
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Fax | 920-236-3558
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Provider Business Mailing Address
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Address Line | 503 DOCTORS CT
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City | OSHKOSH
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State | WI
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Zip | 54901-2025
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Country | US
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Telephone | 920-236-3540
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Fax | 920-236-3558
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STEPHEN S DUDLEY
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Credential | MD
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Telephone | 920-236-3540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TPA2317
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License Number State | WI
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