Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 5350/T2259 | OH |
N | 152W00000X | Optometrist | OEG-000812 | PA |
Y | 152W00000X | Optometrist | OPC 4250 | FL |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 5350/T2259 | OH |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | OEG-000812 | PA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | OPC 4250 | FL |
N | 152WP0200X | Pediatric Optomitrist | 5350/T2259 | OH |
N | 152WP0200X | Pediatric Optomitrist | OEG-000812 | PA |
N | 152WP0200X | Pediatric Optomitrist | OPC 4250 | FL |
N | 152WS0006X | Sports Vision | 5350/T2259 | OH |
N | 152WS0006X | Sports Vision | OEG-000812 | PA |
N | 152WS0006X | Sports Vision | OPC 4250 | FL |
N | 152WX0102X | Occupational Vision | 5350/T2259 | OH |
N | 152WX0102X | Occupational Vision | OEG-000812 | PA |
NPI | 1306819636 |
---|---|
Provider Name | Dr. Edward Steven Wygonik |
First Address | Saint Johns, FL 32259-7222 |
Second Address | Saint Johns, FL 32259-7222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 01/06/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
101463734 0002 | (05) | PA |
1646983 | HIGHMARK GROUP ID (01) | PA |
220961 | COLE MANAGED VISON ID (01) | PA |
220961 | EYEMED ID (01) | PA |
241675 | HLTH AM/ASSR/ADVANTRA ID (01) | PA |
3002066 | AETNA PROVIDER ID (01) | PA |
313229 | UPMC HEALTH PLAN ID (01) | PA |
397597 | NATIONAL VISION ADMIN. ID (01) | PA |
50054 | DAVIS VISION ID (01) | PA |
U91193 | (02) | PA |
WY1395963 | BLUE CRSS/SHLD PROV ID (01) | PA |