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General NPI Number Information
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NPI Number | 1982754685
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Entity Type | Organization
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Legal Business Name | GONNERING EYE CONSULTANTS, S.C.
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2900 W OKLAHOMA AVE
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City | MILWAUKEE
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State | WI
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Zip | 53215-4330
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Country | US
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Telephone | 414-778-3224
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Fax |
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Provider Business Mailing Address
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Address Line | 11716 W GREENFIELD AVE
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City | WEST ALLIS
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State | WI
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Zip | 53214-2156
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Country | US
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Telephone | 414-778-3224
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Fax | 414-778-3886
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Authorized Official
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Title or Position | OWNER
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Name | RUSSELL S GONNERING
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Credential | M.D.
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Telephone | 414-778-3224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 20265020
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License Number State | WI
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