Provider Demographics
NPI:1962555409
Name:RITZENTHALER, THOMAS WAYNE (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WAYNE
Last Name:RITZENTHALER
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 1:222 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-2135
Mailing Address - Country:US
Mailing Address - Phone:608-356-3972
Mailing Address - Fax:608-356-6447
Practice Address - Street 1:222 4TH AVE
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-2135
Practice Address - Country:US
Practice Address - Phone:608-356-3972
Practice Address - Fax:608-356-6447
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1695152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38509800Medicaid
WIT63111Medicare UPIN
WI38509800Medicaid