NPIMap

Organization Active NPI

Summit Eye Clinic SC

  • Optometrist
  • Oconomowoc, WI
National Provider Identifier
1679520845
Registry record updated Mar 11, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
OptometristTaxonomy code 152W00000X
License
1780 Issued in WI
Legal business name
SUMMIT EYE CLINIC SC
Practice address
608 East Summit Ave
Oconomowoc, WI 53066-3841
Phone
(262) 567-6565
Fax
(262) 567-8214
NPI assigned
May 31, 2006
Last updated
Mar 11, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 11, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Randy J Prestash, ODNPI 1760516256
Title
President
Phone
(262) 567-6565

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X 1780 WI Primary

Addresses

Primary practice location

608 East Summit Ave
Oconomowoc, WI 53066-3841

Mailing address

608 E Summit Ave
Oconomowoc, WI 53066
Phone (262) 567-6565

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040207000046 WI Part B Supplier - Clinic/Group Practice 2062305469 Receives reassigned benefits from 1 practitioner
Practice locations: Oconomowoc, WI

National Provider Directory

National Provider Directory

Locations

608 Summit Ave
Summit, WI 53066
Phone (262) 567-6565

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1299801600000",
    "number": "1679520845",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "608 E SUMMIT AVE",
            "city": "OCONOMOWOC",
            "state": "WI",
            "postal_code": "53066",
            "telephone_number": "262-567-6565",
            "fax_number": "262-567-8214"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "608 EAST SUMMIT AVE",
            "city": "OCONOMOWOC",
            "state": "WI",
            "postal_code": "530663841",
            "telephone_number": "262-567-6565",
            "fax_number": "262-567-8214"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUMMIT EYE CLINIC SC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-31",
        "last_updated": "2011-03-11",
        "status": "A",
        "authorized_official_last_name": "PRESTASH",
        "authorized_official_first_name": "RANDY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "262-567-6565",
        "authorized_official_credential": "OD"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": "WI",
            "license": "1780",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Oconomowoc, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 11, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.