MEDICARE: DR. BENJAMIN JOSEPH WHEELER 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	007387	NY
2	152W00000X	Optometrist	2780	TN

General Provider Information

NPI Number	:	1104011485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENJAMIN JOSEPH WHEELER O.D.

Provider Business Mailing Address
First Line	:	428 W 48TH ST
Second Line	:	APT 1 RE
City	:	NEW YORK
State	:	NY
Zip	:	10036
Country	:	US
Telephone Number	:	615-430-6758
Fax Number	:	718-364-7300

Provider Business Practice Location Address
First Line	:	138 E FORDHAM RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5408
Country	:	US
Telephone Number	:	615-430-6758
Fax Number	:	718-364-7300

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

Provider Enumeration Date	:	09/11/2007
Last Update Date	:	05/04/2009

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