MEDICARE: WIARDA OPTOMETRY, PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093958514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WIARDA OPTOMETRY, PLLC

Provider Business Mailing Address
First Line	:	4786 MCMURRY AVE UNIT 2A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4499
Country	:	US
Telephone Number	:	248-467-4422
Fax Number	:

Provider Business Practice Location Address
First Line	:	4786 MCMURRY AVE UNIT 2A
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4499
Country	:	US
Telephone Number	:	970-204-4020
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. NOAH COLE WIARDA
Credential	:	O.D.
Telephone Number	:	248-467-4422

Provider Enumeration Date	:	04/14/2009
Last Update Date	:	03/12/2024

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