MEDICARE: DR. TERRY J WOLTHUIS 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	T567	SD
2	152W00000X	Optometrist	567	SD

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	:	1770524688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRY J WOLTHUIS O.D.

Provider Business Mailing Address
First Line	:	1230 NORTH AVENUE SUITE 3
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783-1572
Country	:	US
Telephone Number	:	605-642-4656
Fax Number	:	605-717-2413

Provider Business Practice Location Address
First Line	:	1230 NORTH AVENUE SUITE 3
Second Line	:
City	:	SPEARFISH
State	:	SD
Zip	:	57783-1572
Country	:	US
Telephone Number	:	605-642-4656
Fax Number	:	605-717-2413

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

Provider Enumeration Date	:	06/10/2006
Last Update Date	:	04/14/2022

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