=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821113697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN WARREN, OD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1139 S SUNNYSLOPE DR STE 203
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53406-3998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 272-752-2020
-----------------------------------------------------
Fax | 262-292-5019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1139 S SUNNYSLOPE DR STE 203
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53406-3998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 272-752-2020
-----------------------------------------------------
Fax | 262-292-5019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN E WARREN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 262-752-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2527
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------