Basic Information
| Provider Information | |||||||||
| NPI: | 1447260245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCGONIGAL | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | NORTH FLORIDA/SOUTH GEORGIA VETERANS HEALTH SYSTEM | ||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867546423 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | NORTH FLORIDA/SOUTH GEORGIA VETERANS HEALTH SYSTEM | ||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867546423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 05/14/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4861/T1726 | OH | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | OE008056P | PA | N | Eye and Vision Services Providers | Optometrist |
No ID Information.