Provider Demographics
NPI:1871763862
Name:WAYNE DOUGHERTY DBA WHEELING OPTICAL
Entity type:Organization
Organization Name:WAYNE DOUGHERTY DBA WHEELING OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-232-6501
Mailing Address - Street 1:1101 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2905
Mailing Address - Country:US
Mailing Address - Phone:304-232-6501
Mailing Address - Fax:304-232-6502
Practice Address - Street 1:1101 MARKET STREET
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-2905
Practice Address - Country:US
Practice Address - Phone:304-232-6501
Practice Address - Fax:304-232-6502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV05 7 00045156FX1800X
WV0507000045332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0151762000Medicaid
1255560001Medicare NSC