Provider Demographics
NPI:1215929989
Name:WIGDOR, STEVEN (OD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:WIGDOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17941 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2502
Mailing Address - Country:US
Mailing Address - Phone:305-931-0225
Mailing Address - Fax:305-931-0238
Practice Address - Street 1:17941 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33160-2502
Practice Address - Country:US
Practice Address - Phone:305-931-0225
Practice Address - Fax:305-931-0238
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001791152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078392700Medicaid
FL5821020002OtherMEDICARE DME SUPPLIER
FL5821020001OtherMEDICARE DME SUPPLIER
FLT54783Medicare UPIN
FL19024YMedicare PIN
FL19024ZMedicare PIN