MEDICARE: DR. DONALD E WIGHT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046.007443	IL

General Provider Information

NPI Number	:	1043260144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD E WIGHT O.D.

Provider Business Mailing Address
First Line	:	6256 E RIVERSIDE BLVD
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4418
Country	:	US
Telephone Number	:	815-708-7083
Fax Number	:	815-904-6294

Provider Business Practice Location Address
First Line	:	6256 E RIVERSIDE BLVD
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4418
Country	:	US
Telephone Number	:	815-708-7083
Fax Number	:	815-904-6294

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	05/07/2018

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