MEDICARE: DR. TARA NICOLE VANDEWYNGAERDE 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	PENDING	IL
2	152W00000X	Optometrist	46009989	IL

General Provider Information

NPI Number	:	1528264603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA NICOLE VANDEWYNGAERDE O.D

Provider Business Mailing Address
First Line	:	807 CLARK ST
Second Line	:
City	:	OGLESBY
State	:	IL
Zip	:	61348-1177
Country	:	US
Telephone Number	:	815-228-7623
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 14TH AVE
Second Line	:
City	:	MENDOTA
State	:	IL
Zip	:	61342-1412
Country	:	US
Telephone Number	:	815-539-6291
Fax Number	:	815-539-3035

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	01/15/2008

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