MEDICARE: DR. EDWARD STEVEN WYGONIK 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	152WC0802X	Corneal and Contact Management Optometrist	OPC 4250	FL
2	152WP0200X	Pediatric Optometrist	OPC 4250	FL
3	152WS0006X	Sports Vision Optometrist	OPC 4250	FL
4	152W00000X	Optometrist	OPC 4250	FL
5	152W00000X	Optometrist	OEG-000812	PA
6	152W00000X	Optometrist	5350/T2259	OH
7	152WC0802X	Corneal and Contact Management Optometrist	OEG-000812	PA
8	152WC0802X	Corneal and Contact Management Optometrist	5350/T2259	OH
9	152WP0200X	Pediatric Optometrist	OEG-000812	PA
10	152WP0200X	Pediatric Optometrist	5350/T2259	OH
11	152WS0006X	Sports Vision Optometrist	OEG-000812	PA
12	152WS0006X	Sports Vision Optometrist	5350/T2259	OH
13	152WX0102X	Occupational Vision Optometrist	OEG-000812	PA
14	152WX0102X	Occupational Vision Optometrist	5350/T2259	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50054	OTHER	PA	DAVIS VISION ID
2	WY1395963	OTHER	PA	BLUE CRSS/SHLD PROV ID
3	3002066	OTHER	PA	AETNA PROVIDER ID
4	220961	OTHER	PA	COLE MANAGED VISON ID
5	397597	OTHER	PA	NATIONAL VISION ADMIN. ID
6	1646983	OTHER	PA	HIGHMARK GROUP ID
7	220961	OTHER	PA	EYEMED ID
8	241675	OTHER	PA	HLTH AM/ASSR/ADVANTRA ID
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	313229	OTHER	PA	UPMC HEALTH PLAN ID

General Provider Information

NPI Number	:	1306819636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD STEVEN WYGONIK O.D.

Provider Business Mailing Address
First Line	:	108 DRUMELLAN CT
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-7222
Country	:	US
Telephone Number	:	412-719-5926
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 DRUMELLAN CT
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-7222
Country	:	US
Telephone Number	:	412-719-5926
Fax Number	:

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	06/01/2009

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