Provider Demographics
NPI:1861885071
Name:STATE UNIVERSITY OF IOWA
Entity type:Organization
Organization Name:STATE UNIVERSITY OF IOWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-467-2125
Mailing Address - Street 1:105 E 9TH ST
Mailing Address - Street 2:STE 2400
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2209
Mailing Address - Country:US
Mailing Address - Phone:319-467-2125
Mailing Address - Fax:319-467-2128
Practice Address - Street 1:105 E 9TH ST
Practice Address - Street 2:STE 2400
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2209
Practice Address - Country:US
Practice Address - Phone:319-467-2125
Practice Address - Fax:319-467-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier