MEDICARE: DR. JON ROBERT WEGNER 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	2647	WI

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	:	1447246046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON ROBERT WEGNER O.D.

Provider Business Mailing Address
First Line	:	1120 GROVE AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-3028
Country	:	US
Telephone Number	:	262-637-7917
Fax Number	:	262-637-6786

Provider Business Practice Location Address
First Line	:	1120 GROVE AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-3028
Country	:	US
Telephone Number	:	262-637-7917
Fax Number	:	262-637-6786

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	03/24/2016

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