Active NPI
Randy Joseph Wild, O.D.
- Optometrist
- Neenah, WI
National Provider Identifier
1891812749
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- 1706
- Practice address
- 1111 Maple St
Neenah, WI 54956-4122 - Phone
- (920) 722-7411
- NPI assigned
- Mar 24, 2007
- Last updated
- Jun 6, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 6
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | 1706 | WI | Primary |
| Corneal and Contact Management Optometrist | 152WC0802X | 1706 | WI | |
| Pediatric Optometrist | 152WP0200X | 1706 | WI | |
| Sports Vision Optometrist | 152WS0006X | 1706 | WI | |
| Vision Therapy Optometrist | 152WV0400X | 1706 | WI | |
| Occupational Vision Optometrist | 152WX0102X | 1706 | WI |
Addresses
Primary practice location
1111 Maple St
Neenah, WI 54956-4122
Mailing address
1111 Maple St
Neenah, WI 54956-4122
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 38509100 | Medicaid | WI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1706 | WI | MD | Sports Vision Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1174694400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1212710400000",
"number": "1891812749",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1111 MAPLE ST",
"city": "NEENAH",
"state": "WI",
"postal_code": "549564122"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1111 MAPLE ST",
"city": "NEENAH",
"state": "WI",
"postal_code": "549564122",
"telephone_number": "920-722-7411"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILD",
"first_name": "RANDY",
"middle_name": "JOSEPH",
"name_prefix": "Dr.",
"credential": "O.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-24",
"last_updated": "2008-06-06",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "WI",
"license": "1706",
"primary": true
},
{
"code": "152WC0802X",
"taxonomy_group": "",
"desc": "Optometrist, Corneal and Contact Management",
"state": "WI",
"license": "1706",
"primary": false
},
{
"code": "152WP0200X",
"taxonomy_group": "",
"desc": "Optometrist, Pediatrics",
"state": "WI",
"license": "1706",
"primary": false
},
{
"code": "152WS0006X",
"taxonomy_group": "",
"desc": "Optometrist, Sports Vision",
"state": "WI",
"license": "1706",
"primary": false
},
{
"code": "152WV0400X",
"taxonomy_group": "",
"desc": "Optometrist, Vision Therapy",
"state": "WI",
"license": "1706",
"primary": false
},
{
"code": "152WX0102X",
"taxonomy_group": "",
"desc": "Optometrist, Occupational Vision",
"state": "WI",
"license": "1706",
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "38509100",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Neenah, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.